Essays on Access to Care for Medicaid Beneficiaries
Open Access DepositedMedicaid beneficiaries face significant barriers to accessing high-quality, timely care. This dissertation, structured as three interrelated papers, explores Medicaid policy from a health workforce perspective, aiming to enhance research and understanding of access barriers to improve public policy. I utilize the Transformed-Medicaid Statistical Information System (T-MSIS) Analytical Files (TAF), a national database of Medicaid claims. In the first paper, I refine existing methods for identifying the primary care and ambulatory specialist workforce by adapting an activity-based classification approach from O’Reilly-Jacob et al. Classifying primary care clinicians is complex because workforce databases may lack accurate specialty information for physicians and typically classify all nurse practitioners (NPs) and physician assistants (PAs) as primary care clinicians, despite many working in other fields. I find that while reported physician specialties are generally reliable for primary care classification, more accurately identifying which NPs and PAs directly billing Medicaid that practice primary care improves accuracy and has workforce policy implications. I use the results in this paper to assess service utilization in the subsequent papers. In the second paper, I investigate the relationship between primary care utilization and the Social Vulnerability Index (SVI). Socioeconomic indexes, which measure social disadvantage through composite scores, are increasingly used to identify areas that may have worse healthcare access, but their relationship to actual service utilization remains unclear. I find that areas with higher rates of social vulnerability are significantly less likely to have even one primary care visit. However, the probability of having a primary care visit at a community health center increases with social vulnerability, showing how important these safety-net facilities are in ameliorating geographic-based disparities. I also examine how each of the underlying SVI variables relate to primary care utilization to understand the key drivers of disparities. In the third paper, I evaluate the impact of accountable care organizations (ACOs) in Massachusetts on the utilization of primary care, specialist services, emergency departments (EDs), and inpatient hospitalizations, with a particular focus on heterogeneity based on patient risk. I find that ACOs increased primary care and specialist utilization, but contrary to policymakers’ expectations, I also find increased ED use and inpatient hospitalizations. The concurrent increase in primary care and ED use suggests complementary patterns rather than the substitutive patterns assumed by policymakers. Utilization increases were driven primarily by low-risk beneficiaries, indicating that ACOs did not fundamentally alter utilization patterns for high-risk patients. While these findings suggest ACOs may have increased healthcare costs, running counter to policy goals, they also point to improved access to care.
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