Association for Public Policy Analysis & Management

Research Objective: Medicaid recipients have consistently reported less timely access to specialists than counterparts with other forms of coverage. By 2018, states will be required to enact “time and distance standards,” for managed care organizations to ensure an adequate supply of specialist physicians for enrollees; however, there have been no studies of whether these policies are likely to be effective in improving access for Medicaid enrollees, and whether they will reduce long-standing disparities in access between Medicaid and commercial enrollees. We examine the impact of previous state-initiated access standards on enrollee ratings of access to specialty care in Medicaid managed care (MMC) and commercial plans.

Study Design: We used data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and a difference- in-differences approach to compare ratings of timely access to specialists for commercial and Medicaid adult enrollees before and after the implementation of specialty access standards. Timely access was operationalized as the proportion of respondents who reported they were always or usually able to obtain a specialist appointment. We identified five states that implemented standard(s) between 2005 and 2011: California, Colorado, Massachusetts, Nebraska and New Mexico. States implementing standards were matched to control states that had previously implemented specialty standard(s) on the basis of managed care penetration and population size. We compared changes in specialty care access for four years prior and two years following the implementation of access standards using generalized linear regression models that included demographic and plan level controls, and fixed effects to account for time invariant characteristics.

Population Studied: 57,453 non-elderly MMC enrollees in 10 states, and 58,200 commercial enrollees in five states who reported trying to access specialists.

Principal Findings: 60.4% of Medicaid enrollees in states without access standards prior to the study period reported timely access to specialists as compared to 68.0% of enrollees in states that had previously implemented access standards. Nationally, there was no significant improvement in timely access to specialty services for MMC enrollees in the period following implementation of standard(s) (adjusted difference-in-differences: -1.2 percentage points [95% CI, -2.7, 0.1]), nor was there any impact of access standards on insurance based disparities in access (0.6 percentage points [95% CI, -4.3, 5.4]). There was heterogeneity across states, with one state that implemented both time and distance standards demonstrating significant improvements in access and reductions in disparities.

Conclusions: The adoption of specialty access standards did not lead to widespread improvements in access to specialist physicians. Our analysis shows that this policy alone is unlikely to lead to widespread improvements in access to health care services for Medicaid enrollees, and may not reduce gaps in specialty care access between Medicaid and commercial enrollees. States and the federal government should consider other approaches to augment the expected effects of these policies, such as ensuring the adequacy of physician networks, and leveraging emerging policy and organizational strategies to improve enrollee access to specialists.