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Doctor and patient

Two national studies reveal the disparities for patients seeking access to primary care, maternal health and behavioral health.

There are two reports that were recently published that address concerns related to access in primary care services. 

The first report titled Access to Services in Medicaid and the Marketplaces: Comparing Network Adequacy Rules was released on March 30 from Georgetown University, Center on Health Insurance Reforms.  The findings highlighted not only the discrepancies between coverage for Managed Medicaid plans (MCOs) compared to marketplace plans, but also issues with both plans in ensuring consumers access to primary care, maternal health, and behavioral health across states and geographic regions.

The paper compares both types of health plans and acknowledges a significant deficit in the coverage rights and standards for marketplace plans.  Such as, many states require MCOs to provide distance standards for access to primary care, mental health, and OB/GYN, however there are no such requirements for marketplace plans.  Meaning, the member that is paying a significant amount in their marketplace health plan may also be faced with lack of coverage, limited appeal rights, and long travel distances for basic care because of the limited provider network associated with their health plan. The minimum amount of contract providers also varies by state for Medicaid members. We see this when look for primary care, specialist, mental health providers, and even post-acute and the selection is limited and inconsistent across MCO plans.  

To address concerns impacting provider coverage for access to care, the report makes recommendations to enhance marketplace plan requirements to include health equity across regions, access to essential community providers, and more consumer transparency and protections. For MCOs, the report is requesting minimum federal standards to ensure consistency across MCOs and across state lines, including an audit process for the performance and adherence to standards for MCOs.  

The second report comes from the Commonwealth Fund, released last week, which expands upon their 2020 health report related to maternal mortality.  The research reminds us that the U.S. has the highest rate of maternal deaths among high-income countries, and black women are nearly three times more likely to die from pregnancy related complications than white women.

The 2022 update found that women of reproductive age (18-49) were significantly more likely to have problems with paying their medical bills or to skip or delay needed care because of costs.  This population also has the highest rates for multiple chronic conditions and the highest rate of mental health needs and were less likely to have a primary care physician or medical home in comparison to the high-income countries in the study.

The report recommends ensuring basic access to affordable health care and investment in primary care, maternal health, and mental healthcare which are all areas that have been acknowledged as having a limited workforce to keep up with the demand of consumers requiring access to such needed services.


Tiffany Ferguson, LMSW, CMAC, ACM

Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the care management company. Tiffany serves on the ACPA Observation Subcommittee. Tiffany is a contributor to RACmonitor, Case Management Monthly, and commentator for Finally Friday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles for Health and Care Management and c-level responsibility for a large employed medical group. Tiffany received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.

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