52% of OR Medicaid Providers Never Saw Medicaid Enrollees in 2018

The Oregon Medicaid program’s provider directories may have included hundreds or thousands of providers who never saw Medicaid enrollees, according to a Health Affairs article.

“Understanding the extent to which beneficiaries can ‘realize’ access to reported provider networks is imperative in mental health care, where there are significant unmet needs,” the researchers explained.

“Significant discrepancies between the providers listed in directories and those whom enrollees can access suggest that provider network monitoring and enforcement may fall short if based on directory information.”

The researchers used data on Oregon’s Medicaid enrollees—excluding those who were dual eligible or receiving fee-for-service care—from January 1, 2018 through December 31, 2018. They also used a provider directory—the Delivery System Network Provider Capacity Report from 2018. Oregon relies on coordinated care organizations for Medicaid care delivery.

The directories included almost 7,900 primary care providers, 722 mental health prescribers, and 6,824 mental health nonprescribers in Oregon’s Medicaid managed care networks. 

However, when compared with claims data, the researchers discovered that the actual number of providers available was less. There were nearly 1,400 fewer primary care providers, 140 fewer mental health prescribers, and 874 fewer mental health nonprescribers than the directories reported.

Specialty mental health prescribers had the highest lowest provider-to enrollee ratio, with the directories portraying five times the number of prescribers that the claims data did. There were 4.0 mental health prescribers per 1,000 enrollees according to the directories, but claims data showed only 0.7 prescribers per 1,000 enrollees. These disparities fluctuated between coordinated care organizations.

The researchers started by taking the directory and claims data together. Looking at both data sources, they found that more than half of the unique providers were part of the phantom network, meaning that they were cited in the directory but did not receive any claims data (51.8 percent). 

Additionally, almost a third of the providers were in the directory and did have claims data attesting that they met with a Medicaid enrollee (32.4 percent). Another 15.7 percent were in the claims data but not present in the directory.

Six out of ten primary care providers in the directory had contracts with more than one coordinated care organization (61.2 percent), along with 63.9 percent of specialty mental health prescribers and 36.1 percent of nonprescribing mental health specialists.

When the researchers homed in on the directory data, they found that 58.2 percent of the providers in the directory did not see Medicaid enrollees in 2018. Mental health prescribers were most likely to be in the phantom network (67.4 percent), followed by mental health nonprescribers (59.0 percent) and, not far behind, primary care providers (54.0 percent).

A minority of all providers in the directory (41.8 percent) had claims data attesting that they saw a Medicaid enrollee in 2018.

“Across all provider types, lower realized access was associated with smaller median patient panel sizes,” the researchers noted.

The median panel size for mental health prescribers was highest at 70 enrollees. The median panel size for mental health nonprescribers was nearly half that size (34.5 enrollees).

While inaccuracies in provider directories are important to study and can have serious implications for enrollees’ out-of-pocket healthcare spending, healthcare providers’ availability is also important to track.

Payer collaboration with providers could help inform provider directories by improving data collection and updates, according to a white paper from CAQH and the American Medical Association.

Consumers have gravitated toward provider search tools in 2022, as transparency tools become more available.