The Medicaid expansion implemented under the Affordable Care Act added about 35,000 Clark County residents to the state health plan for low-income people.
What the expansion did not do, however, was increase the number of providers in the community offering primary care services to those patients.
The Health Care Authority — the state agency overseeing the Washington Apple Health Medicaid program — says Clark County already has a sufficient number of primary care providers to meet the need of Medicaid clients.
Providers and health plans paint a different picture.
Some provider groups have limited the number of Medicaid clients they will see, saying they can’t afford to treat them, given the low reimbursement rates from the state. Others are trying to expand to keep up with demand but are struggling to recruit providers.
Meanwhile, both of the county’s Medicaid managed care plans are working to expand their provider networks and meet client needs.
“I think we’ve, overall, managed to keep up,” said Karen Lee, president and chief executive officer of Columbia United Providers, a Vancouver-based Medicaid managed care plan. “That doesn’t mean it’s been easy. It’s been a really interesting juggling act.”
Network strength
Prior to the Medicaid expansion in January 2014, Clark County had about 80,000 residents enrolled in Medicaid programs. As of March, that number had grown to more than 115,000 enrollees.
Despite the 44 percent increase in enrollees, the Health Care Authority says Clark County health plans have been able to meet the primary care needs of Medicaid clients.
“Based on our analysis, we actually see pretty strong primary care access,” said Preston Cody, an assistant director with the Health Care Authority.
The state requires Medicaid managed care plans to meet certain network adequacy requirements in order to have clients assigned to their plan. Each plan must have enough primary care providers to meet a ratio of 1,200 patients per provider, Cody said. Plans must also meet network requirements for certain types of specialty providers.
In Clark County, two managed care plans meet those requirements: Molina Healthcare of Washington and Columbia United Providers, or CUP.
Columbia United Providers has the largest share of Clark County Medicaid clients — about 50,000 enrollees. CUP’s primary care network includes about 200 providers — 160 of whom are in family medicine and internal medicine, 40 of whom are pediatric providers.
Molina has about 22,000 Clark County Medicaid clients and nearly 300 primary care providers in its network — 151 in Clark County and another 139 providers in Portland.
Those primary care provider numbers do not distinguish between providers who accept a limited number of Medicaid clients (and, in some cases, have reached that limit) and providers who have an open door to Medicaid. The Health Care Authority’s analysis does factor in those limited patient caseloads.
A third plan, Community Health Plan of Washington, meets the state’s minimum standard for primary care, but the Health Care Authority is not assigning clients to the plan because of limitations within its specialty care network, Cody said. Medicaid clients can, however, choose that plan. The plan had about 20,000 local members, as of February.
“We have adequate networks,” Cody said. “Even with the expansion, we have adequate networks.”
Changing environment
Those networks — particularly Columbia United Provider’s network — have seen some changes in the last year.
Last May, The Vancouver Clinic announced it would no longer accept new Medicaid clients and would reduce the amount of Medicaid services it provides over the following three years. At the time, The Vancouver Clinic provided primary care for more than 36,000 Medicaid clients in Clark County. The organization now has about 20,000 primary care Medicaid clients.
Declining reimbursement rates — they fell 50 percent over three years — and the increasing number of Medicaid clients threatened the clinic’s financial stability, clinic officials said.
The end of the clinic’s open-door policy meant CUP, which contracts with The Vancouver Clinic, had to find other options for Medicaid clients.
Even with that change, Cody said the community has enough providers.
“If a provider like The Vancouver Clinic scales back, that may mean the person has to change providers, but it doesn’t mean they don’t have a provider to see,” Cody said.
Access issues
Not everyone agrees.
Molina serves Medicaid clients in every county in the state. Clark County is experiencing primary care access problems unlike other urban areas in Washington, said Peter Adler, president of Molina Healthcare of Washington.
“In general, Clark County is an outlier, at least in Molina’s experience,” he said.
The primary care access challenges are due to two issues, Adler said.
First, not all primary care providers in Clark County are willing to work with Medicaid clients. That, Adler said, leads to a disproportionate distribution among those who are willing to see Medicaid clients.
“They end up feeling the distress of a practice with a disproportionate share of Medicaid,” he said. “The problem compounds itself.”
The second issue is a shortage of primary care providers. It’s a problem affecting communities across the country, and Clark County is no different.
“The systemic issue is people don’t want to go into primary care,” said Dr. Dino Ramzi, a physician at Lacamas Medical Group and past president of the Clark County Medical Society. “I think it’s more acute in Clark County because of the growth in the last decade. Primary care docs just haven’t kept up with it.”
Community response
Sea Mar Community Health Centers in Clark County is adding more providers to its clinics, expanding its clinic space and increasing its patient load to meet the needs of new Medicaid members. But Sea Mar has struggled to recruit providers, said Dr. Tony Stupski, a primary care provider at Sea Mar’s Vancouver Medical Clinic.
“They’re ready and willing to expand, just the providers are not there,” he said.
Sea Mar is a federally qualified health center. Because of that, it receives additional federal funding to provide health care services for people on Medicaid. The Sea Mar clinics are the only qualified health centers in Clark County.
But that also means clinic providers aren’t paid as well as those who work in private practice or in specialty care. The patients they care for tend to have more complex health issues, as well, Stupski said.
Sea Mar’s Medicaid client population has climbed to about 35,000 people. Before the expansion, Sea Mar’s clinics served about 10,500 Medicaid clients. The result has been long wait times for appointments — sometimes up to two months, Stupski said.
Still, Sea Mar has been able to improve access for its patients, particularly for those who need specialty care, said Michael Bejenaru, a Sea Mar clinic manager, at a Community Health Access Resource Group meeting earlier this month.
“Personally, I’m very encouraged by the improvements we’ve seen in the last six months in terms of access,” Bejenaru said.
Molina has been working to expand, as well. Since July, Molina has added more than 10 provider groups to its network to keep up with the health plan’s Medicaid enrollment numbers, which have grown from about 10,000 members in February 2014 to about 22,000 people, as of April 1.
Molina is also trying to support those who care for Medicaid patients by embedding case managers and care coordinators in medical clinics. In addition, Molina is offering providers an alternative reimbursement method — a set amount of money each month to care for members, rather than payments for specific services.
“Instead of fee-for-service, it moves the incentives to keeping people healthy,” Adler said. “It allows them to begin focusing more on going upstream with the members.”
Finally, Molina is piloting a new 24/7 virtual urgent care program in Tacoma that it hopes to move to Vancouver next, Adler said.
Members can use computer video chats or phones to connect with a Seattle-based physician for urgent care needs. The physician can triage patients, directing them to an emergency room, if necessary, and provide a consult. After the visit, the patient notes are sent directly to the person’s primary care provider, Adler said.
The program is designed to meet members’ needs after regular clinic hours, keep people with non-emergent issues out of the emergency room and alleviate the rush of appointment requests at clinics after the weekend, Adler said.
Columbia United Providers has also been working on its network, mainly to account for the loss of providers from The Vancouver Clinic. CUP had to get creative to replace those primary care slots, said Dr. Tanya Dansky, CUP’s chief medical officer, at the community health access meeting this month.
CUP’s provider relations team met with contracted providers and asked them for help. They asked some to increase the number of clients they accepted. They urged hesitant physicians to keep their patient caseloads open to Medicaid. They also worked to bring a new provider, Dr. Matthew Rose, to Vancouver. He opened Rose Urgent Care and Family Practice, a clinic aimed at serving the Medicaid population, in February.
The result was community action to support Medicaid clients.
“Access is obviously extremely important,” Dansky said. “This whole community really did chip in.”
