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Physician Assistants as Medicaid Managed Care Providers
Background
Financed jointly by the federal government and states, Medicaid is the nation's health care lifeline for two statutorily defined groups of low-income residents -- families, primarily women and children; and the aged, blind and disabled. In reality, Medicaid is not one, but rather 56 separate programs that differ dramatically across state lines. While federal law mandates who is eligible for coverage and the broad categories of services that must be provided, each participating state designs and administers its own program by (1) setting certain income and asset eligibility requirements; (2) selecting which optional groups and services to cover; and (3) determining the scope of mandatory and optional services.
In recent years, Medicaid costs have tripled and the number of beneficiaries increased by over 50 percent. Current projections suggest that program costs will double over the next five to seven years. To constrain rising health care costs, states are increasingly turning to mandatory enrollment of some or all Medicaid beneficiaries in managed care delivery plans -- arrangements that limit a beneficiary's choice of providers and hospitals. In many cases, these managed care plans are prepaid a fixed amount per enrollee. This financing arrangement has demonstrated the ability to lower service utilization, which in turn can hold down costs.[1] Through managed care, many states also hope to expand coverage to the uninsured working poor. As compared with fee-for-service systems, managed care can offer Medicaid beneficiaries more coordinated forms of care and a greater likelihood of having a primary care provider. [2]
By June 1994, 7.8 million Medicaid beneficiaries were enrolled in managed care plans, double the number enrolled a year earlier. [2]
Medicaid managed care arrangements typically involve a primary care provider who acts as gatekeeper and coordinates the delivery of care. State Medicaid programs include different professionals in their lists of primary care providers. Family physicians, general practitioners, pediatricians and internists are routinely included. Some states also define physician assistants, obstetricians/gynecologists, and nurse practitioners as primary care providers. Some jurisdictions specify that PAs and NPs may serve in association with physicians, that physicians may be supported by PAs and advanced practice nurses, or that the managed care organization may determine the composition of the primary care network. [3]
When implementing Medicaid managed care systems, states are also responsible for developing and maintaining a sufficient provider network to ensure access to care.3 In addition to determining which categories of providers are eligible to participate in the network, their geographic proximity, and patient access to specialty care, a decision is made on the maximum number of Medicaid beneficiaries enrolled per provider. In Texas, for example, primary care providers would be limited to a maximum of 1500 clients unless circumstances justified a special exemption.[3]
Medicaid managed care administrators in several states have struggled with the question of how many beneficiaries to enroll per physician assistant. Their decisions have usually allotted to physician assistants a number equal to 20-100 percent of the Medicaid patients assigned to a physician.
Physician Assistants as Medicaid Providers
As states experiment with different methods of providing and holding down the cost of medical care, it is important to recognize the contributions that physician assistants can make in this process. In 42 states, PAs provide Medicaid beneficiaries with quality health care services. Studies show that there is little difference in the level of patient satisfaction when care is provided by a PA as opposed to a physician.
Numerous independent studies have concluded that the quality of medical care provided by PAs is equivalent to that of physicians when PAs are practicing within the scope of their education and training. As far back as 1986, the Office of Technology Assessment found that "PAs provide care that is equivalent in quality to the care provided by physicians."[4]
Medicaid-eligible residents who are located in areas with limited access to primary care services often find it difficult, if not impossible, to obtain health care services. This situation can lead to instances in which residents do not seek necessary primary care and enter the health care system when illnesses have progressed, resulting in higher medical costs. States have found that including PAs in the medical teams that care for Medicaid patients can help alleviate this costly problem.
A relatively high proportion of PAs practice in areas with large Medicaid populations. It is in the best interest of the state to sustain the cost effective delivery of services to Medicaid beneficiaries by those practices that have demonstrated a commitment to caring for this patient population. Moreover, it is important to promote continuity of care. When patients are satisfied with their current providers, they should be allowed, or even encouraged, to continue to utilize them under a Medicaid managed care system.
Studies on physician assistants in managed care indicate that PAs are as productive as physicians. Using a random five percent sample of all patient visits in one year, researchers at one managed care entity determined that physicians and PAs saw similar types and numbers of patients.[5]
Recommendations
Physician assistants, practicing with physician supervision, are a critical part of the health workforce providing care for Medicaid patients. To facilitate the continued delivery of services to these patients, the AAPA believes that states should include the following provisions in Medicaid managed care plans:
- Physician assistants should be recognized as primary care providers, either by naming them specifically with their supervising physicians, or by naming them within a group.
- Physician assistants should be included on the list of providers in order to allow Medicaid beneficiaries the option of seeking care from a physician/PA team that may in fact already be serving as their current providers.
- States should assign a maximum patient panel that recognizes the proven productivity of PAs and physicians and does not provide a disincentive for utilizing PAs on the health care team. This can be achieved by increasing a supervising physician's panel size by an appropriate number or by directly paneling the PA.
REFERENCES
Updated: 6/97
- Medicaid Section 1115 Waivers. J Washington, DC: General Accounting Office, 1995. (GAO/HEHS-96-44.)
- Iglehart JH. Medicaid and Managed Care. J N Engl J Med 1995; 332:1728.
- Texas 1115 Medicaid Waiver Summary. Austin, TX: Texas Health & Human Services Commission. August 15, 1995.
- Nurse Practitioners, Physician Assistants and Certified Nurse Midwives: A Policy Analysis. Washington, DC: US Congress Office of Technology Assessment; 1986.
- Hooker RS. The Roles of Physician Assistants and Nurse Practitioners in a Managed Care Organization. In Clawson DK and Osterweis M, eds., The Roles of PAs and NPs in Primary Care. Washington, DC: Association of Academic Health Centers, 1993.
Last Revised: 4/2/02
