Causes and potential cures for states with Medicare access problems

Rapid growth in Alaska senior populations, coupled with increasing numbers of physicians who either opt out of Medicare or see only established Medicare patients, has decreased access to primary-care services for this group.

One response to address this situation is to enhance financial incentives for primary-care physicians to increase their acceptance of Medicare beneficiaries. Another is to target increased support toward the safety net of community health centers.

To compare these two approaches, we developed a simplified demand and supply model of primary care in Alaska based on (1) our 2008 census of primary-care physician practices; (2) a review of community health center patient trend data; (3) emergency room patient trend data; (4) estimates of the net reimbursement rates for Medicare, Medicaid, private insurance, and self-insured payers and their relative ratios over time; and (5) a comparison of our Alaska demand and supply model estimates to a sample of other Western states selected for both high and low percentages of Medicare beneficiaries reporting “big problems” in finding a personal doctor or nurse. In Anchorage, 25% of primary-care physicians have opted out of Medicare; 56% are limiting Medicare access to their existing patients; and only 17% are accepting new Medicare patients. Interviews and review of trend data suggest that a significant factor behind limited and declining access for Medicare beneficiaries is that Medicare pays roughly 60% of the rate of private insurance for primary care in Alaska compared to roughly 70% in Washington State. Meanwhile, the Anchorage Neighborhood Health Center, a community health center, has seen the percentage of patients who are 65 and older more than double between 2001 and 2007—from 6% to 13.5%—while the Medicare beneficiary population visits to the hospital emergency room have remained flat.

Our preliminary findings suggest that, while targeting increased support toward the community health centers may be a more cost-effective way to sustain access than an across-the-board increase in Medicare reimbursement rates, a combination of enhanced support for critical access facilities and operations and a change in Medicare reimbursement measures may be needed to achieve a publicly acceptable level of access to primary care.