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so the the problem i'm trying to research is that medicaid underpays doctors
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and when medicaid underpays doctors it's hard for patients who have medicaid insurance to
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get to get to find the doctors they need to get the care they need either the providers that typically give care to
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low-income patients are you know struggling with their their finances or they they go out to doctors in the
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community and a lot of them don't want to see the patients that where they don't get paid a lot of money
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so as part of the affordable care act they decided to pay medicaid doctors more they pay them the same amount that
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they pay medicaid patients that like doubled the amount they got paid for those doctors that saw patients for
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for primary care um so the question is that we are studying um is are there more doctors willing to
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see these medicaid patients when they're paid like twice as much as they were
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before and as an economist it seems like a pretty obvious answer to that question that you
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know you you get paid more you're more likely to see patients but this was a critical policy question
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because this was a policy that was in and put in place for just two years just to see how well it worked
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um and and the hope was is that doctors would engage the system at a time where medicaid was expanding they're more
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patients available so what we did was we called up these practices pretended we had field workers who
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pretended they were patients and they said uh can i get a new patient appointment and then we just mark down
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whether they got an appointment or not it was as simple as that half the time those scripts included
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patients who had medicaid insurance and have time for a control group they had private insurance
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and we did this exact same study in 2012 before this policy went to effect and then again this past
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spring in 2014 right in the middle of the um of this implementation of this policy
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and we uh um and we saw about an eight percentage point jump in the percentage of uh patients who were
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getting appointments and uh what was really uh compelling about our findings was there's great variation between
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states in terms of how much pay increase because medicaid pays different amounts
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it's a state-run program and so for some states the jump was double 100 jump in others maybe 30 or 40
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percent in those states where the jump was double um the increase in appointment rates
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were about 15 and in those states where as much lower is about five percent so you saw this
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um much greater increase when they got paid even more and then when we looked in the private
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insurance group as a control to say you know maybe there's something else going on during
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the same time we saw no change at all so with some pretty compelling results it really suggested this policy worked
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to increase appointment availability for primary care physicians when you pay them more
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money in the medicaid system well this is a very uh timely research for um for policymakers
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it was a two-year policy that ended january 2015. so policymakers were really interested in whether this
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policy worked so the key takeaway is the policy worked um and another key takeaway
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is that um there's a debate about why patients why doctors don't see medicaid
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patients and what this suggests is that if you pay them reasonably they show up to see
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these patients that it's really about payment and it's not the fact that there
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may not be enough providers i mean there's some areas where there may not be enough providers
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overall but the solution if if physicians aren't seeing medicaid patients is to pay them adequately um
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this seems to our results seem to show it makes a difference when we started this study
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uh there was a lot of hesitation because it was the very beginning of this policy implementation as i said as
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a two-year policy it was starting up in 2013 and that was when we were getting ready for our second round
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um of data collection uh implementation was delayed by six months they had real trouble uh figuring
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out exactly how to pass through payments there's like capitated managed care
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it's a lot easier when it's a fee for service than when it's capitated so
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struggles with implementation and a lot of people said well the the payment is temporary
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and so doctors aren't going to change their patterns for a temporary policy and the other thing that we had heard is
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that a lot of physicians weren't really calling up the medicaid office and saying you know gee i really want to be
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in this program so a lot of the anecdotal evidence was pointing towards there really no
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being no action so at the end of the summer it was like september we took our first peek at the results
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and we were all very surprised um to see such a large unambiguous effect so really the surprise was that we found
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something particularly when the rhetoric at the time was that this policy really
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wasn't having an impact well i think the most practical implication um you know i guess i think about it for
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for policy makers a lot of discussion at the state level states were trying to decide if they
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wanted to you know extend this uh pay bump uh policy and uh what they were saying at the time
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was you know there's no evidence yet so we're not going to make a decision
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because there's no evidence but now we have evidence so i think the real practical
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um implication for people who are kind of on the front lines of deciding whether doctors should be paid more for
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this specific policy is that um you know there's there's evidence and evidence-based policy is an
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important way to make policy and here this policy seems to work but you know i think there's a a broader point that
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that can be made that's important for physicians who run businesses um and you know i think physicians are not
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um immune to the same economic incentives as anyone else running a business um you know i think that there's
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uh when you're talking about health there might be some you know maybe moral obligation to see everyone
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who comes in your office but you're you can't have an office that that can turn the light on unless
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you can pay the bills and when you don't pay enough to to you know turn the lights on to to see
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the patients who you know the reimbursement is like 30 or 40 dollars for a half hour of your time it's really
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hard for some of these doctors to justify that um in their day they're just trying to
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um you know have have a business where where they bring in more money than they spend so i think what this suggests is
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from a practical end particularly as someone who's running a business is that you know physicians are running
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businesses too um and they shouldn't be you know set up against different rules
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than than you know other businesses you know there's a lot of debate in congress right now
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i wouldn't say a lot of debate in congress but um this policy uh of this what we call the medicaid
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rate bump was introduced um in the president's budget just a couple weeks ago in february he he proposed to
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congress that they extend the pay bump for another two years and make some modifications
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and there's a lot that's going on in washington to to make some decisions
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about various aspects of health policy it's all very very political but from a practical end this is about a
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six billion dollar a year policy to pay medicaid providers for primary care at the same rate
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as uh as they pay for medic or pay medicaid doctors the same amount as medicare and cost six billion dollars which is
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really a drop in the bucket when you think of the trillion dollar medicaid you know aca bill um and so i
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think the practical implications is you know we know that there are some effects
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important effects for patients getting access to providers having continuity of care and there this
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provides some evidence that um that there's a benefit of this policy and you know that
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now the politicians have to decide um if that that payment you know that expenses is
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worth is worth it for the gain that you get the focus here was on primary care physicians
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in medicaid and that's what the policy was aimed at but uh in medicaid it's it's really difficult
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not only uh in some areas not only to get um access to primary care providers but
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if you have a need for specialty care it could be even more difficult the payment
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gaps for specialty care can be even more severe so the implications extend beyond primary
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care you pay doctors more they're more likely to extend appointment availability
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to patients with that insurance type and i think it would extend beyond primary care providers specialty care providers
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and in particular areas where that access is a real issue you know it suggests that that paying
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specialty providers more money would help address that problem there was a front page article
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in the times right in december when this two-year policy ended it was always a temporary policy
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and so payment rates doubled two years ago but when they went back down in uh january 1st the headline was doctors get
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pay cuts of 50 you know will they still see patients so i mean at that time it was a 50
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reduction in in the amount they were getting paid within medicaid but that was certainly a
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headline at the time um so i think uh what you know i believe you know what goes up is
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probably going to come down so in response to the headline what will happen now that rates
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uh payment rates have gone back down i think we can expect that the gains that we saw in the
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last two years in terms of more doctors participating in medicaid will probably go back down
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and you know we'll go back in the field and measure it but i think for for the
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impact on medicaid patients i think it's an important finding you know there's a perception
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that there are fewer doctors that see medicaid patients maybe it's because doctors
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don't want to see medicaid patients and what this research suggests is that if you pay them reasonably
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um they'll show up to to see these patients and and it's more about the payment rates than it is about something
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about this patient population this is the first time we've been able to look at the relationship
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between payment rates and physician appointment availability or just you know access participation
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medicaid program using experimental methods so other people have looked um in data those states that have higher
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payment rates tend to have more doctors that participate versus low but it could be
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for a number of reasons that doctors set up their era that that medicaid sets up payment rates that
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way and it's just observational but to be able to go into the field pose as um
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as patients actually seeking appointments measure real behavior and kind of this
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audit methodology in this experimental way where we randomized the scripts to having medicaid or private insurance
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we've controlled for other aspects of of access really sets us apart really clean design
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that is able to that has this compelling narrative that you know you actually are
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measuring it by calling up doctor's offices i think just that that audit methodology is very compelling for um
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people on the street if you say i ran a regression analysis and my p-value was whatever somehow you've already lost
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half the crowd so it was both a clean experimental design i think very compelling easily to relate to finding
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this uh paper that i was telling you about is is part of a much larger project larger data collection
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effort which is about um tracking how um how available physicians are for seeing
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patients around the insurance expansions of the affordable care act so in the past
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couple of years it's been a large group of people 10 15 million who didn't
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have insurance before and now have insurance and will be demanding uh to see doctors in ways that they haven't
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before because they have insurance to cover those visits so the fear is that that there won't be enough doctors to to
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meet this increased demand for care so we did our baseline measures in 2012 before insurance expanded and in a
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number of different domains we're studying whether um uh whether there's sufficient capacity
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in the um in the work in the physician workforce to meet this increased demand are we going to see a squeeze on the
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medicaid side our private uh um for private insurance and one of the questions that
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people are curious about is whether those people have always had insurance you know the question is will their care
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remain the same but if their doctors are so busy because they're more patients
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maybe for them even their care won't be the same and we'll be able to measure
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that we'll have you know these baseline data to know that what things are like
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before we can monitor changes we're going to look at changes look at the access issues
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that exist in health insurance exchanges so there's a lot of questions we're
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still pursuing with this larger ongoing work we're hoping to go back in the field
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to collect the third round of data within the next six to 12 months you