HCM 340 Module 4 Access to Care Short Paper example

A Card Is Not an Appointment: Coverage, Availability and Access to Mental Health Care for Medicaid Enrollees

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Southern New Hampshire University

HCM 340: Healthcare Delivery Systems

Module Four Short Paper

[Instructor Name]

[Date]

A Card Is Not an Appointment: Coverage, Availability and Access to Mental Health Care for Medicaid Enrollees

Coverage and Access Are Not the Same

Public debate about healthcare often treats insurance coverage as if it were access to care. Coverage matters, because it determines whether care is affordable, but a person with a Medicaid card still needs a clinician who is nearby, taking new patients, open at a usable time and willing to accept that coverage. When any of those conditions fails, the coverage produces no care. This distinction is sharpest in mental health, where demand is high, many clinicians work outside insurance networks, and delays can have serious consequences. This paper examines the gap between coverage and availability for Medicaid enrollees seeking mental health care, using a recognized framework of access and two kinds of published evidence.

A Framework for Access

Penchansky and Thomas (1981) defined access as the degree of fit between patients and the healthcare system, and described it in five dimensions. Availability is whether enough providers and services exist to meet need. Accessibility is whether patients can physically reach them, considering distance and transportation. Accommodation is whether the way services are organized, such as appointment systems and hours, suits patients. Affordability is whether patients can pay, which insurance addresses. Acceptability is whether patients and providers are comfortable with each other, including providers' willingness to serve patients with certain coverage. Later work extended the model to include patients' ability to perceive a need, seek care, reach it, pay for it and engage with it (Levesque et al., 2013). Insurance acts on one of the five dimensions; the other four decide whether the card is ever used.

Evidence One: Networks That Exist on Paper

Medicaid managed care plans must maintain networks of providers and publish directories that enrollees use to find care. Zhu et al. (2022) tested whether those directories reflected reality in Oregon's Medicaid program. They compared the clinicians listed in plan directories with the clinicians who actually filed claims for at least five of the plan's enrollees during 2018. Overall, 58.2 percent of directory listings were phantom providers who did not see Medicaid patients. The problem was worst in mental health: 67.4 percent of listed mental health prescribers, such as psychiatrists and psychiatric nurse practitioners, and 59.0 percent of nonprescribing mental health clinicians saw no Medicaid patients, compared with 54.0 percent of primary care providers.

The implication is striking. A plan could meet a regulator's standard for network adequacy based on its directory while most listed clinicians would never see its members. An enrollee working through the list would call provider after provider without finding one who would schedule them, which is precisely the experience the next body of evidence measures.

Evidence Two: Trying to Book the Appointment

Simulated-patient studies, sometimes called secret shopper studies, test availability directly by having researchers call practices as patients. Malowney et al. (2015) called 360 psychiatrists listed in a major insurer's database in Boston, Chicago and Houston, posing as patients with Blue Cross Blue Shield, with Medicare or paying out of pocket. On the first round, callers reached only 33 percent of the psychiatrists. After two rounds of calls, they secured appointments with just 26 percent. Differences between cities were significant, but differences by payer were not, suggesting that even well-insured patients faced the same wall.

The authors concluded that expanding insurance coverage alone may do little to improve access to psychiatrists and could further strain the capacity of existing services. The study did not include Medicaid callers, whose results would likely have been worse given lower payment rates and the directory findings from Oregon, but it shows that the availability problem exists across payer types.

Reading the Evidence Through the Framework

Applied to these findings, the framework explains why coverage failed to become care. Affordability was addressed by insurance in every case. Availability failed first: there were not enough psychiatrists taking new patients to meet demand. Acceptability failed next: many clinicians listed as participating did not in practice accept Medicaid patients, often because payment rates are low and administrative requirements are heavy. Accommodation failed in the form of unanswered calls and unreturned messages, and for rural enrollees accessibility would add distance to the list. Each dimension is a separate point of failure, and a patient needs all five to succeed.

Who Bears the Gap

The gap between coverage and availability does not fall evenly. Medicaid enrollees are affected most because their plans pay less, so they reach the end of a phantom list sooner than privately insured patients. People with serious mental illness are affected because their symptoms can make repeated calling, waiting and following up harder, which means the burden of navigating a broken directory falls on those least able to carry it. Rural enrollees face the problem twice, since fewer clinicians practice nearby to begin with. Families seeking care for children meet the same shortage in child psychiatry, and parents often take time off work to make calls during office hours. When access fails, these patients do not simply go without; many end up in emergency departments during a crisis, where care is more expensive and less suited to ongoing treatment. The cost of the gap therefore reappears elsewhere in the system, usually at a higher price.

Implications for the Delivery System

The findings point to three changes. First, regulators should measure network adequacy using claims, which show who actually delivers care, rather than directories, which show who signed a contract. Second, periodic simulated-patient audits should be required of health plans, with results made public, because they measure the experience enrollees actually have. Third, availability must be expanded, not only covered, through higher Medicaid rates for mental health services, integration of behavioral health into primary care, and use of telehealth and non-physician clinicians to add capacity. Coverage expansion remains necessary, but without these steps it risks promising care the system cannot deliver.

For healthcare managers, the lesson is practical. A health system that counts its insured patients as served, without measuring how long they wait for a first appointment, will overestimate its own access. The more useful measure is the time from a patient's first request to a completed visit, tracked by payer, because that is the point at which coverage either becomes care or does not.

References

Levesque, J.-F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12, Article 18. https://doi.org/10.1186/1475-9276-12-18

Malowney, M., Keltz, S., Fischer, D., & Boyd, J. W. (2015). Availability of outpatient care from psychiatrists: A simulated-patient study in three U.S. cities. Psychiatric Services, 66(1), 94-96. https://doi.org/10.1176/appi.ps.201400051

Penchansky, R., & Thomas, J. W. (1981). The concept of access: Definition and relationship to consumer satisfaction. Medical Care, 19(2), 127-140. https://doi.org/10.1097/00005650-198102000-00001

Zhu, J. M., Charlesworth, C. J., Polsky, D., & McConnell, K. J. (2022). Phantom networks: Discrepancies between reported and realized mental health care access in Oregon Medicaid. Health Affairs, 41(7), 1013-1022. https://doi.org/10.1377/hlthaff.2022.00052