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so the the problem i'm trying to
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research is that medicaid underpays
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doctors
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and when medicaid underpays doctors it's
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hard for
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patients who have medicaid insurance to
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get to get to find the doctors they need
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to get the care they need either the
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providers that typically give care to
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low-income patients are you know
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struggling with their their finances or
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they they go out to doctors in the
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community and a lot of them don't want
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to see
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the patients that
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where they don't get paid a lot of money
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so
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as part of the affordable care act
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they decided to pay medicaid doctors
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more they pay them the same amount that
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they pay
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medicaid patients that like doubled the
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amount they got paid
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for those doctors that saw patients for
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for primary care
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um
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so the question is that we are studying
00:00:58
um is are there more doctors willing to
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see these medicaid patients when they're
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paid like twice as much as they were
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before and as an economist it seems like
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a pretty
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obvious answer to that question that you
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know you you get paid more you're more
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likely to see patients
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but this was a critical policy question
00:01:16
because this was a policy that was in
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and put in place for just two years just
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to see how well it worked
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um
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and and the hope was is that doctors
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would engage the system at a time where
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medicaid was expanding they're more
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patients available
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so what we did was
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we called up these practices
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pretended we had field workers who
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pretended they were patients
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and they said uh can i get a new patient
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appointment and then we just mark down
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whether they got an appointment or not
00:01:44
it was as simple as that half the time
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those scripts included
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patients who had medicaid insurance and
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have time for a control group they had
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private insurance
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and we did this exact same study
00:01:56
in 2012 before this policy went to
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effect and then again this past
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spring in 2014 right in the middle of
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the um
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of this implementation of this policy
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and we uh
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um
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and we saw
00:02:12
about an eight percentage point jump in
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the percentage of uh patients who were
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getting appointments and uh what was
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really uh compelling about our findings
00:02:21
was there's great variation between
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states in terms of how much pay increase
00:02:26
because medicaid pays different amounts
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it's a state-run program
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and
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so for some states the jump was
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double 100 jump in others maybe 30 or 40
00:02:36
percent in those states where the jump
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was double
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um the increase in appointment rates
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were about 15
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and in those states where as much lower
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is about five percent so you saw this
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um
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much greater increase when they got paid
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even more
00:02:51
and then when we looked in the private
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insurance group
00:02:54
as a control to say you know maybe
00:02:56
there's something else going on during
00:02:58
the same time we saw no change at all so
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with some pretty compelling results it
00:03:02
really suggested this policy worked
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to increase
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appointment availability for primary
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care physicians when you pay them more
00:03:10
money in the medicaid system
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well this is a very uh
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timely research for
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um for policymakers
00:03:22
it was a two-year
00:03:25
policy that ended january 2015. so
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policymakers
00:03:30
were really interested in whether this
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policy worked so the key takeaway is the
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policy worked
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um
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and another key takeaway
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is that um
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there's a debate about why
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patients why doctors don't see medicaid
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patients
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and what this suggests is that if you
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pay them reasonably they show up to see
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these patients that it's really about
00:03:53
payment and it's not the fact that there
00:03:56
may not be enough
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providers i mean there's some areas
00:03:58
where there may not be enough providers
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overall but the solution if if
00:04:02
physicians aren't seeing medicaid
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patients is to pay them adequately um
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this seems to our results seem to show
00:04:08
it makes a difference
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when we started this study
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uh there was a lot of hesitation
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because it was the very beginning of
00:04:21
this policy implementation as i said as
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a two-year policy it was starting up in
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2013 and that was when we were getting
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ready for our second round
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um of data collection
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uh implementation was delayed by six
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months they had real trouble uh figuring
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out exactly how to pass through payments
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there's like capitated managed care
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it's a lot easier when it's a fee for
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service than when it's capitated so
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struggles with implementation and a lot
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of people said well the the payment is
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temporary
00:04:53
and so doctors aren't going to change
00:04:55
their patterns for a temporary policy
00:04:57
and the other thing that we had heard is
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that a lot of
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physicians
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weren't really
00:05:03
calling up the medicaid office and
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saying you know gee i really want to be
00:05:06
in this program so a lot of the
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anecdotal evidence
00:05:09
was pointing towards there really no
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being no action
00:05:12
so at the end of the summer it was like
00:05:13
september we
00:05:15
took our first peek at the results
00:05:17
and we were all very surprised um to see
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such a large unambiguous effect so
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really the surprise was that we found
00:05:25
something particularly when the rhetoric
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at the time was that this policy really
00:05:30
wasn't having an impact
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well i think the most
00:05:37
practical implication
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um
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you know i guess i think about it for
00:05:42
for policy makers
00:05:45
a lot of discussion at the state level
00:05:48
states were trying to decide if they
00:05:50
wanted to you know extend this
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uh pay bump
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uh policy
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and uh what they were saying at the time
00:05:58
was you know there's no evidence yet so
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we're not going to make a decision
00:06:01
because there's no evidence but now we
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have evidence so i think the real
00:06:05
practical
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um implication for people who are kind
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of on the front lines of deciding
00:06:10
whether doctors should be paid more for
00:06:12
this specific policy
00:06:14
is that um you know there's there's
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evidence and evidence-based policy is an
00:06:20
important way to make policy and here
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this policy seems to work but you know i
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think there's a a broader point that
00:06:26
that can be made that's important
00:06:28
for physicians who run businesses
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um
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and you know i think physicians are not
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um
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immune to the same economic
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incentives
00:06:40
as anyone else running a business
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um
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you know i think that there's
00:06:45
uh when you're talking about health
00:06:47
there might be some
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you know
00:06:49
maybe moral obligation to see everyone
00:06:53
who comes in your office but you're you
00:06:55
can't have an office
00:06:56
that that can turn the light on unless
00:06:59
you can pay the bills and
00:07:02
when you don't pay enough to
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to you know turn the lights on to to see
00:07:07
the patients who you know the
00:07:08
reimbursement is like 30 or 40 dollars
00:07:11
for a half hour of your time it's really
00:07:13
hard for some of these doctors to
00:07:15
justify that um in their day they're
00:07:17
just trying to
00:07:18
um you know have have a business where
00:07:21
where they bring in more money than they
00:07:22
spend so i think what this suggests is
00:07:25
from a practical end particularly as
00:07:27
someone who's running a business
00:07:29
is that you know physicians are running
00:07:31
businesses too um and they shouldn't be
00:07:33
you know set up against different rules
00:07:35
than
00:07:35
than you know other businesses
00:07:41
you know there's a lot of debate in
00:07:43
congress right now
00:07:44
i wouldn't say a lot of debate in
00:07:45
congress but um this policy
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uh of this what we call the medicaid
00:07:50
rate bump was introduced um in the
00:07:53
president's budget just a couple weeks
00:07:55
ago in february he he proposed to
00:07:57
congress
00:07:59
that they extend the pay bump for
00:08:00
another two years and make some
00:08:02
modifications
00:08:05
and there's a lot that's going on in
00:08:07
washington to to make some decisions
00:08:10
about
00:08:11
various aspects of health policy it's
00:08:13
all very very political
00:08:14
but from a practical end this is about a
00:08:17
six
00:08:18
billion dollar a year
00:08:20
policy to pay medicaid providers for
00:08:22
primary care at the same rate
00:08:24
as
00:08:26
uh
00:08:27
as they pay for medic or pay medicaid
00:08:30
doctors the same amount as medicare
00:08:34
and cost six billion dollars which is
00:08:36
really a drop in the bucket when you
00:08:38
think of the trillion dollar
00:08:41
medicaid you know aca bill um and so i
00:08:44
think the practical implications is you
00:08:46
know we know that there are some effects
00:08:47
important effects for patients
00:08:49
getting access to providers having
00:08:51
continuity of care and there this
00:08:54
provides some evidence
00:08:55
that um
00:08:57
that there's a benefit of this policy
00:08:58
and you know that
00:09:00
now the politicians have to decide
00:09:02
um if that
00:09:04
that payment you know that expenses is
00:09:06
worth is worth it for the gain that you
00:09:08
get
00:09:13
the focus here was on primary care
00:09:16
physicians
00:09:18
in medicaid and that's what the policy
00:09:21
was aimed at
00:09:22
but uh
00:09:24
in medicaid it's it's really difficult
00:09:26
not only
00:09:27
uh in some areas not only to get
00:09:30
um access to primary care providers but
00:09:32
if you have a need for specialty care it
00:09:34
could be even more difficult the payment
00:09:36
gaps for specialty care can be even
00:09:39
more severe
00:09:40
so
00:09:43
the implications extend beyond primary
00:09:45
care you pay doctors more
00:09:47
they're more likely to extend
00:09:51
appointment availability
00:09:53
to patients with that insurance type and
00:09:55
i think it would extend beyond primary
00:09:56
care providers specialty care providers
00:09:59
and in particular areas where that
00:10:01
access is a real issue
00:10:04
you know it suggests that that paying
00:10:06
specialty
00:10:08
providers more money would help address
00:10:10
that problem
00:10:15
there was a front page article
00:10:17
in the
00:10:18
times right in december
00:10:21
when this two-year policy ended it was
00:10:23
always a temporary policy
00:10:25
and so payment rates doubled two years
00:10:28
ago
00:10:29
but
00:10:30
when they went back down in uh
00:10:33
january 1st the headline was doctors get
00:10:36
pay cuts of 50
00:10:39
you know will they still see patients so
00:10:41
i mean at that time it was a 50
00:10:43
reduction in in the amount they were
00:10:45
getting paid
00:10:47
within medicaid but that was certainly a
00:10:49
headline at the time
00:10:51
um so i think
00:10:53
uh
00:10:54
what
00:10:55
you know
00:10:57
i believe you know what goes up is
00:10:59
probably going to come down so
00:11:02
in response to the headline what will
00:11:03
happen now that rates
00:11:05
uh payment rates
00:11:07
have gone back down i think we can
00:11:10
expect that the gains that we saw in the
00:11:12
last two years in terms of more doctors
00:11:14
participating
00:11:16
in medicaid will probably go back down
00:11:19
and
00:11:20
you know we'll go back in the field and
00:11:22
measure it but i think for for the
00:11:23
impact on
00:11:24
medicaid patients i think it's an
00:11:26
important finding
00:11:31
you know there's a perception
00:11:33
that
00:11:34
there are fewer doctors that see
00:11:35
medicaid patients maybe it's because
00:11:37
doctors
00:11:38
don't want to see medicaid patients
00:11:41
and what this research suggests
00:11:43
is that if you pay them reasonably
00:11:46
um they'll show up to to see these
00:11:48
patients and and it's more about the
00:11:50
payment rates than it is about something
00:11:51
about this patient population
00:11:57
this is the first time we've
00:12:00
been able to look at the relationship
00:12:02
between payment rates
00:12:04
and
00:12:06
physician appointment availability or
00:12:08
just you know access participation
00:12:10
medicaid program using experimental
00:12:12
methods so other people have looked um
00:12:15
in data those states that have higher
00:12:17
payment rates
00:12:18
tend to have more doctors that
00:12:20
participate versus low but it could be
00:12:21
for a number of reasons that doctors set
00:12:23
up their era that
00:12:25
that medicaid sets up payment rates that
00:12:27
way and it's just observational
00:12:29
but to be able to
00:12:31
go into the field
00:12:32
pose as um
00:12:35
as patients actually seeking
00:12:37
appointments
00:12:38
measure real behavior and kind of this
00:12:41
audit methodology
00:12:44
in this experimental way where we
00:12:46
randomized the
00:12:47
scripts
00:12:49
to having medicaid or private insurance
00:12:51
we've controlled for other aspects of of
00:12:53
access
00:12:55
really sets us apart
00:12:58
really clean design
00:13:00
that
00:13:02
is able to
00:13:03
that has this compelling
00:13:05
narrative that you know you actually are
00:13:07
measuring it by calling up doctor's
00:13:09
offices i think just that that audit
00:13:11
methodology is very compelling for um
00:13:14
people on the street if you say i ran a
00:13:16
regression analysis and my p-value was
00:13:18
whatever somehow you've already lost
00:13:20
half the crowd so
00:13:22
it was both a clean experimental design
00:13:24
i think very
00:13:25
compelling easily to relate to finding
00:13:32
this uh paper that i was telling you
00:13:35
about is is part of a much
00:13:37
larger project larger data collection
00:13:39
effort
00:13:40
which is about um
00:13:42
tracking
00:13:43
how um
00:13:45
how available physicians are for seeing
00:13:48
patients
00:13:49
around
00:13:50
the insurance expansions of the
00:13:52
affordable care act so in the past
00:13:54
couple of years it's been a large
00:13:58
group of people 10 15 million who didn't
00:14:01
have insurance before and now have
00:14:02
insurance and will be demanding uh to
00:14:04
see doctors in ways that they haven't
00:14:06
before because they have insurance to
00:14:08
cover those visits so the fear is that
00:14:12
that there won't be enough doctors to to
00:14:14
meet this increased demand for care
00:14:18
so we did our baseline measures in 2012
00:14:20
before insurance expanded and in a
00:14:22
number of different domains we're
00:14:24
studying whether um
00:14:27
uh
00:14:28
whether there's sufficient capacity
00:14:31
in the um in the work in the physician
00:14:33
workforce to meet this increased demand
00:14:35
are we going to see a squeeze on the
00:14:37
medicaid side
00:14:38
our private uh
00:14:40
um for private insurance and one of the
00:14:42
questions that
00:14:44
people are curious about
00:14:47
is
00:14:47
whether those people have always had
00:14:49
insurance
00:14:50
you know the question is will their care
00:14:52
remain the same but if their doctors are
00:14:54
so busy because they're more patients
00:14:55
maybe for them even their care won't be
00:14:57
the same and we'll be able to measure
00:14:59
that we'll have you know these baseline
00:15:01
data to know that what things are like
00:15:03
before we can monitor changes we're
00:15:05
going to look at changes look at the
00:15:07
access issues
00:15:08
that exist in health insurance exchanges
00:15:11
so there's a lot of questions we're
00:15:12
still pursuing with this larger
00:15:15
ongoing work we're hoping to go back in
00:15:18
the field
00:15:19
to collect the third round of data
00:15:21
within the next six to 12 months
00:15:47
you
