Medicaid Specialty Access Standards Did Not Result in Better Access to Specialists

The specialty access standards adopted by some state Medicaid programs have not had the desired outcome of making specialty care more accessible for beneficiaries who seek such care, a new study finds.

Barriers to timely specialty care have persisted in Medicaid, as beneficiaries tend to have poorer access to specialists than patients with commercial insurance, according to the research published in JAMA Internal Medicine. New Medicaid managed care rules that will go into effect by 2018 will require states to implement specialty access standards, both time-based, which require specialty appointments to be made within a certain timeframe, and distance-based, which specify the maximum distance or time a patient must travel to see a specialist.

Although several states have already enacted similar access standards in their Medicaid programs, there is little evidence indicating whether these rules have actually been effective in expanding specialist networks and ensuring timely appointments. In the current study, researchers looked at the effects of these standards in 5 states on specialty access as measured by patient surveys.

During the study period of 2005-2011, 5 states (California, Colorado, Massachusetts, Nebraska, and New Mexico) implemented specialty care access standards based on time and/or distance. The researchers used Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses to compare specialty care access for Medicaid managed care beneficiaries in these states and a group of matched control states that had implemented specialty standards prior to the study period.

In 4 of the 5 states analyzed, there were no statistically significant effects observed on reported specialty care access resulting from the implementation of specialty access standards. In Nebraska, however, which was the only state to create standards relating to both appointment wait time and provider distance, the percentage of patients reporting via CAHPS that it was always or usually easy to get a specialist appointment increased significantly after the standards were implemented.

The researchers also found that specialty access standards generally did not reduce access disparities between Medicaid managed care beneficiaries and patients in commercial plans. Both before and after access standards were put in place, commercial enrollees were more likely to report they had good access to specialty care. However, the insurance-based access gap decreased by 10.9% after standards implementation in Nebraska, the state that also had the improvements in specialty access.

Based on these findings, the researchers suggested that “standards alone may not consistently lead to meaningful improvements in access to specialty care,” considering that they are difficult to enforce. The study authors wrote that more innovative solutions may be required to expand access to specialty care in Medicaid and reduce insurance-based disparities, such as accountable care organizations or telemedicine consults, as well as strengthened enforcement of specialty access standards.

An editorial accompanying the research by Chima D. Ndumele, PhD, and colleagues agreed with the idea that telehealth specialty consults could help expand access to care. However, editorial author Mitchell H. Katz, MD, noted that investments in primary care and the social determinants of health may be more helpful for Medicaid beneficiaries than focusing solely on specialty access. He also argued that specialty access standards fail to take into account nuances among patients with differing levels of clinical need.

“Access standards, which Ndumele show us may not be effective, cannot substitute for good clinical judgement or wise use of scarce resources,” Katz concluded.