Our research indicates that the adoption of Medicaid managed care could have differential effects on specialist and primary care physicians' participation in Medicaid, which would result in decreased access to specialists for Medicaid managed care patients. While specialists were more likely than primary care physicians to accept new Medi-Cal patients overall, specialists were more likely to differentiate between Medi-Cal fee-for-service and managed care patients. Specialists were far less likely than primary care physicians to accept new Medi-Cal managed care patients. This apparent physician distinction between Medicaid fee-for-service and Medicaid managed care has emerged with the creation of Medicaid managed care. In the early 1990s, before the introduction of Medicaid managed care, a survey of office-based physicians found specialist physicians were more likely to accept new Medicaid patients than were their primary care counterparts.9
While both primary care and specialist physicians hold several potentially negative attitudes about Medi-Cal patients, these attitudes, with one exception, do not predict whether the physicians are willing to accept new Medi-Cal patients. It is likely that these negative opinions are outweighed by economic or social considerations. Earlier studies of traditional Medicaid found the level of reimbursement and density of physicians to be the strongest predictors of level of physician participation.7,9,19–21
The one exception is the belief that Medi-Cal patients increase the risk of being sued. There has been a long-standing belief among health care providers that the poor and Medicaid patients in particular are more likely than other patients to pursue legal action against physicians.19,22–24
This fear persists despite a number of reports that indicate otherwise.23,25–27
Better dissemination of such information may help convince physicians that Medicaid patients are not more likely to sue and may increase physician willingness to accept new Medicaid patients.
Physician attitudes toward Medi-Cal patients and toward the Medi-Cal managed care program also do not predict physician willingness to accept new Medi-Cal managed care patients, again with one exception. Physicians who agreed that managed care was improving the Medi-Cal program overall were more likely to accept new Medi-Cal managed care patients. Agreement with specific program mechanics, such as making it easier to obtain tests and consults, however, were not predictive. As with Medi-Cal in general, attitudes toward Medi-Cal managed care may be outweighed by other factors, particularly economic and social. In Arizona, primary care physicians tended to participate in Medicaid managed care in large part because of reimbursement and their belief in government social programs, even with negative attitudes toward patients and plan administration.12
Participation of primary care physicians in Kansas Medicaid managed care was most strongly predicted by several variables that all related to reimbursement.13
Our analysis suggests that a decrease in specialist participation and the resultant decrease in access to specialists with Medicaid managed care might be mitigated if states are able to contract with group model HMOs. Physicians in this practice setting were more likely to take new Medi-Cal patients in general and were much more likely to take new Medi-Cal managed care patients. In such group model HMOs, the decisions regarding contracting may be made by HMO executives and not individual physicians. Future efforts to increase access to specialist care for Medicaid patients might be successful if such efforts aimed to get Medicaid beneficiaries enrolled in group model HMOs. Targeted expansion of Medicaid managed care into group model HMOs, however, may not be feasible. In California, for example, there were only 2 group model HMOs operating in 1998. Together these 2 plans enrolled approximately 19% (4,568,177) of all privately insured Californians under the age of 6528
but less than 1% (29,104) of all Medi-Cal beneficiaries.14
In addition, African-American, Asian and Latino physicians were more likely to accept new Medi-Cal patients and new Medi-Cal managed care patients compared to white physicians. Previous work before the introduction of Medicaid managed care similarly found minority primary care physicians more likely to care for Medicaid patients.8,22
Our finding of decreased specialist participation and likely decreased access to specialists in Medicaid managed care is in contrast to some earlier work. In New York, Sisk et al. documented patient self-reported improved access to outpatient services for Medicaid managed care beneficiaries compared to Medicaid fee-for-service beneficiaries.29
The access items, however, asked about having a usual source of care and about seeing the same clinician and most likely measure access to primary care physicians and not to specialists. In addition, unlike the mandatory Medicaid managed care program in California, the program in New York was voluntary, allowing for the possibility that patient self-selection could explain the reports of improved access to care for those in Medicaid managed care.
It is important to note certain limitations of our analysis. First, our analysis is limited to physicians in California and may not be generalizable to physicians in other states. Second, the data are derived from physicians' self-reports. While previous research has documented that physicians tend to overestimate the absolute number of Medicaid patients in their practices, they are quite accurate in their reports about nonparticipation.30
Third, since this is a cross-sectional survey, cause and effect for having a positive attitude toward Medi-Cal managed care and accepting new Medi-Cal managed care patients cannot be assigned. Finally, this survey was conducted relatively early in the expansion of Medi-Cal managed care and it therefore may not reflect patterns of care that were yet to develop.
Judging by specialists' reports of being far less likely to take Medi-Cal managed care patients compared to traditional Medi-Cal patients, expansion of managed care Medicaid will likely decrease specialist participation in Medicaid managed care and consequently decrease access of Medicaid patients to specialists. This decrease in access may be mitigated if states are able to contract with group model HMOs and to recruit minority physicians. The lack of sufficient numbers of group model HMOs willing to contract with Medicaid and recent declines in minority enrollments in U.S. medical schools,31
however, may mean that states will have to seek other means to avert a decrease in health care access for Medicaid managed care beneficiaries. Negative attitudes toward Medicaid patients and Medicaid managed care, while pervasive, do not appear to predict acceptance of new Medicaid patients. Further research may try to identify other mutable physician or system characteristics that could be addressed to increase physician participation in the Medicaid program.