medipass primary care physician network analysis: primary ...€¦ · elsewhere. the data sheet...

MediPass Primary Care Physician Network Analysis: Primary Findings Allyson Hall, PhD Heather Steingraber, MAC (ABT) Steve Shaffer Christy Harris Lemak, PhD Jianyi Zhang, PhD

Florida Center for Medicaid & the Uninsured College of Public Health and Health Professions

University of Florida 352/273-5059

Sponsored by

The Agency for Health Care Administration

June, 2004

Introduction

Assuring that there is adequate primary care capacity is critical to the success of Medicaid primary care case

management programs, such as MediPass. Several earlier studies documented that physician participation in

Medicaid varies considerably throughout the country, and there has been a decline in participation in recent years.

In 2001, about 85 percent of all physicians throughout the country participated in Medicaid. However, for most

physicians, their Medicaid practice tends to be small – contributing less than 10 percent to overall total practice

revenues (Cunningham, 2002). Nationally, the number of physicians who will not accept new Medicaid patients

increased from 26 percent to 31 percent between 1999 and 2001 (Schoenman, 2003). And, in Alabama and

Georgia, the introduction of a primary care case management program similar to MediPass, actually resulted in

lower physician participation in Medicaid (Adams, et al, 2003). Low reimbursement levels, burdensome paperwork,

and persistently negative opinions about Medicaid are said to be some of the reasons for low physician

participation in some communities (Berman et al, 2003; Perloff et al, 1995; Bindman at al, 2003).

In Florida, a 2002 evaluation concluded that Florida MediPass had excess primary care capacity. At the time,

there were over 4,685 contracted providers or groups providing a capacity that was 10 times greater than the

enrolled MediPass population. The report noted that in order to keep costs down, Medicaid may want to consider

reducing the size of the MediPass network so as to exert control over providers and to assure greater efficiency

within the program(Florida Center for Medicaid Issues, 2002).

PRELIMINARY FINDINGS – DO NOT QUOTE WITHOUT PERMISSION OF THE AUTHORS

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This earlier study relied on data that did not consider whether physicians were accepting new Medicaid

patients. Physicians may be contracted with MediPass, but limit their practice to a few existing patients. Thus, while

it may appear that a community or region has adequate coverage, this may in fact not be the case if only a few

physicians are taking additional patients. In addition, the MediPass program has instituted a requirement that for

all program enrollees, a PCP must be located within 30 minutes drive time of their home. Therefore, simply looking at

the number of physicians in an area without appropriate consideration of the drive time rule may lead to an

overestimation of PCP capacity.

To address this issue, the Florida Center for Medicaid and the Uninsured contacted MediPass primary care

physicians to learn if they are accepting new Medicaid patients. Mapping analysis then examined the extent to

which there is sufficient MediPass primary care capacity throughout the state.

Methods

Sample Participating MediPass primary care physicians were identified from lists supplied by Medicaid area offices

and from a list generated by QueryPath. The various lists were combined resulting in a master list of over 3,000

unique providers identified by their unique provider IDs.

Survey The main goal of the project was to collect information on whether physicians were accepting new MediPass

patients and to understand some of the barriers MediPass patients may encounter in trying to make appointments

with their PCPs. It was important to ensure that interviewers engaged in realistic dialogue with office staff, and that


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interviewers could easily document findings from these conversations. Therefore interviewers used a basic script

that asked: whether the provider was accepting new patients in general, whether they were accepting MediPass

patients specifically, and if so, how long it would take to get an appointment. Physicians’ offices were generally not

aware that they were being surveyed.

In a training session, interviewers role-played and tested the script with several initial calls. Modifications were

made based on these pilot calls. During and after the call other information was also recorded, such as the length

of time the interviewer spent on hold, and the number of times they were transferred. This information was gathered

in order to capture the ‘hassle factor’ involved in trying to get an appointment. This information will be reported

elsewhere. The data sheet used to collect this information is included in Appendix 1.

Data Analysis Florida Medicaid requires a MediPass Providers to be within a 30-minute drive of every enrollee. This

criterion was used to create MediPass provider service areas based on 30-minute drive times out in every direction

from the provider’s address. Creating drive time service areas for every accepting MediPass provider in the state will

allow for the identification of gaps in service.

Geographic Information Systems (GIS) is a standard tool for mapping and exploring variation in the demand

and supply of health care services (McLafferty, 2003). In this analysis GIS was used to place a point on a map for

every MediPass provider by geocoding based on the provider’s address or zip code. MediPass beneficiaries were

also geocoded by zip code. Service area polygons were then created by a network analysis of the statewide


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street system radiating out from each provider’s point location. The drive time computation took into account

distances and speed limits along the network. Traffic congestion and other travel costs were also taken account by

the GIS system. Service areas for each provider were merged together to provide complete coverage area for the

state for all accepting providers and for specific provider types, such as pediatricians or ob-gyns. Maps and other

data were then produced to show service areas statewide and highlight gap areas where no provider was within a

30-minute drive time of beneficiary zip codes.

Findings The series of maps and charts presented here summarize preliminary findings from the survey and mapping

exercise. A total of 3,800 physicians were identified as either being on an area office list or were listed in QueryPath.

Eighty-eight percent of all physicians surveyed said that they were accepting new patients. However, when

probed, a smaller percentage of offices (74 percent) responded that they were actually taking new MediPass

patients.

With a few exceptions, statewide coverage by MediPass physicians appears to be good. Using the 30-minute

drive-time rule discussed earlier, most of the state’s MediPass population appears to have appropriate access to a

primary care provider. Areas of concern include parts of south Florida including Monroe county, and communities

in south central areas and in the Panhandle. Of particular concern is the lack of pediatric and obstetrics and

gynecology physicians in certain areas.


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Figure 1 – Percent of Florida MediPass Physicians by County who are Accepting New Patients

92 90 93 89

74

65

83 86 83

70

90888988

7671

0

20

40

60

80

100

FloridaBroward

DadeDuval

Hillsborough

OrangePalm Beach

Pinellas

New Patients New MediPass Patients

Area Office

* Includes physicians who are either on an area office or QueryPath list

The majority of MediPass providers are

continuing to accept new MediPass

patients. When asked, 88 percent of

offices said they will see new patients

However, when asked specifically about

Medicaid patients, 74 percent of

providers will see a new MediPass

patient. Acceptance of new MediPass

patients varies across communities. In

Broward only 65 percent of identified

MediPass physicians will take a new

patient, compared to 86 percent in Duval

county.


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Figure 2 – Percent Of MediPass Physicians On An Area Office List Who Are Accepting New Patients

9892 92

97

85

9691 88

77

59

7074 76

95

58

71 74

8385888590

66

97

0

20

40

60

80

100

Florida1 2a 3 4 5 6 7 8 9 10 11

New Patients New MediPass PatientsArea Office

Area offices supplied lists of

providers who are accepting new

MediPass patients. These are the

same lists that are given to MediPass

beneficiaries. Statewide, 77 percent

of physicians on an area office list

will see new MediPass patients. This

ranges from a low of 58 and 59

percent in Areas 8 and 1 respectively,

to a high of 97 percent in Area 4.


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Figure 3 – Percent of MediPass Physicians on An Area Office List who are Accepting New Patients: Statewide, by Specialty

92 90

77 78

65

9094

879190 91

81

0

20

40

60

80

100

All FP/GPInternal Med

OB/GYNPeds

Other

New Patients New MediPass Patients

Area Office

Ninety percent of the OB/GYN physicians

surveyed will see new MediPass patients,

compared to 65 percent of Internal

Medicine physicians. Although there are

high acceptance rates among OB/GYNs,

coverage is inadequate because of the

relatively small numbers of participating

OB/GYN physicians (see Figures 16 and

17).


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Figure 4 – MediPass Providers Statewide

As expected, most of the MediPass

physicians are located in the major

metropolitan areas of Miami-Dade, Ft.

Lauderdale, West Palm Beach, Tampa,

Orlando, and Jacksonville…….


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Figure 5 – MediPass Enrollees by Zip Code Area

…..which is where most of the MediPass

beneficiaries live.


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Figure 6 – MediPass Provider Service Areas

The gray area represents areas within 30

minutes of a MediPass provider (also called

service area). Most of Florida’s populated

areas are within 30 minutes of a MediPass

provider. A few small, wealthy communities

are not within 30 minutes of a MediPass

provider.


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Figure 7 – Ratio of MediPass Enrollees to Accepting Providers Located within a 30-minute Drive Time

Ft. Walton Beach, Century, and Pensacola

Panama City and Perry Gainesville, Lake City, Daytona Beach and Chiefland

Port St. Lucie

Key West and Marathon Immokalee, Arcadia, and Okeechobee

Most MediPass beneficiaries live within

30 minutes drive time of a primary care

provider. However, some communities

(identified by the blue squares) rely

heavily on a few providers to deliver

care to MediPass patients. MediPass

patients could experience access barriers

if these providers should withdraw from

Medicaid.

However, Medicaid areas with large

numbers of providers may wish to

consider downsizing their networks in

order to exert control over providers and

to assure greater efficiency.


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Figure 8 - Ratio of MediPass Enrollees to Accepting Providers within a 30-minute Drive Time: Pensacola and Surrounding Areas

Zip codes 32536 (Century),

32506 , 32505, 32501

(Pensacola) and 32547 (Ft.

Walton Beach) have high

enrollee to provider ratios.


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Figure 9- Ratio of MediPass Enrollees to Accepting Providers within a 30-minute Drive Time: Panama City and Surrounding Areas

Zip codes 32401, 32404,

32405 (Panama City) and

32348 (Perry) have high



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Figure 10- Ratio of MediPass Enrollees to Accepting Providers within a 30-minute Drive Time: Southwest Florida

Zip codes 34142 (Immokalee),

34266 (Arcadia), 34972 and 34974

(Okeechobee) have high enrollee to

provider ratios


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Figure 11- Ratio of MediPass Enrollees to Accepting Providers within a 30-minute Drive Time: North Central Florida

Zip codes 32055 (Lake City), 32607,

32609(Gainesville) and 32177 (Palatka)

have high enrollee to provider ratios.


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Figure 12 - Ratio of MediPass Enrollees to Accepting Providers within a 30-minute Drive Time: Fort Pierce and Surrounding Areas

Zip codes 34950, 34982 (Ft.

Pierce) and 34972 (Okeechobee)

have high enrollee to provider

ratios.


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Figure 13 - Ratio of MediPass Enrollees to Accepting Providers within a 30-minute Drive Time: The Florida Keys

Zip codes 33040 (Key

West) and 33050

(Marathon) have high



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Figure 14 – MediPass Pediatric Provider Service Areas

The brown color represent areas within 30

minutes of a MediPass pediatric provider.

The green areas are not located within 30

minutes of a MediPass pediatric provider.

Several communities, indicated by red dots

are without a pediatric provider.


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Figure 15 – Ratio of MediPass Child Enrollees to Accepting Pediatric Providers Located within a 30-minute Drive Time

Areas with high enrollee to pediatric

provider ratios include Immokalee,

Labelle, Okeechobee, Arcadia,

Gainesville, Tallahassee, Pensacola,

and Century. These areas have

relatively few providers.


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Figure 16 – MediPass OB/GYN Provider Service Areas

The pink area represents areas within 30

minutes of a MediPass OB/GYN

provider. The green areas are not

located within 30 minutes of a MediPass

OB/GYN provider. Many communities,

indicated by red dots are without

OB/GYN physicians within 30 minutes.


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Figure 17 – Ratio of Adult Female MediPass Enrollees to Accepting OB/GYN Providers Located within a 30-minute Drive Time

Almost one-third the state appears to have

a high patient to provider ratio. This may

be an indication of poor access OB/GYN

services among women enrolled in

MediPass.


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References Adams EK, Bronstein JM, Florence CS (2003) The Impact of Medicaid Primary Care Case Management on Office-Based Physician Supply I Alabama and Georgia Inquiry 40 (Fall 2003): 269-282. Berman S, Dolins J, Tang, SF and Yudkowsly B (2002) Factors that Influence the Willingness of Private Primary Care Pediatricians to Accept More Medicaid Patients Pediatrics 110(2 part 2): 239-248. Bindman AB, Yoon J, and Grumbach K (2003) Trends in Physician Participation in Medicaid. The California Experience Journal of Ambulatory Care Management 26(4): 334-343. Cunningham PJ (2002) Mounting Pressures: Physicians Serving Medicaid Patients and the Uninsured. 1997-2001. Center for Studying Health System Change. Tracking Report 6: 1-4. Florida Center for Medicaid Issue (2002) Evaluation of the Florida Medicaid MediPass Program, University of Florida, College of Public Health and Health Professions Perloff JD, Kletke P and Fossett JW (1995) Which Physicians Limit their Medicaid Participation and Why? Health Services Research 30 (1): 7 -26 McLafferty SL (2003) GIS and Health Care Annual Review of Public Health 24: 25-42. Schoenman JA and Feldman J (2003) Results of the Medicare Payment Advisory Commission’s 2002 Survey of Physicians. Washington DC: Medicare Payment Advisory Commission.


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APPENDIX 1 – DATA COLLECTION SHEET Provider Name: «PROVIDER_NAME» Phone: «OFFICE_PHONE» Address: «ADDRESS» City: «CITY» County: «County» Practice Type: «Practice_Type» Specialty: «Specialty» Attempt 1 Attempt 2 Attempt 3 Attempt 4 Date & Time

Interviewer

# Rings

Phone Tree? Y/N

# Transfers

Hold Time

Still Accepting New Patients (Stop if No)

Still Accepting MediPass Patients

(Stop if No)

How long to Appt?

(If >1 week) Even if sick?

Taking Kids? Y/N

After hours & Weekends?

Courteous & Professional? VC, SC, SD, VD

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