Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study

Joy Melnikow; Ethan Evans; Guibo Xing; Shauna Durbin; Dominique Ritley; Brock Daniels; Lindsey Woodworth

doi:10.1370/afm.2502

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Figure 1
Cross-county comparison of Medi-Cal PCC new patient appointment availability using the PCC new patient access ratio.
Medi-Cal = California Medicaid; PCC = primary care clinician.
Note: Error bars indicate 95% CIs. The ratio reflects the number of Medi-Cal patients potentially in need of a new patient appointment with a PCC (the numerator) per available PCC appointment in the county (the denominator). A higher ratio signifies worse access to primary care. More enrollees per available appointment represents a greater demand relative to available appointment.
^aWorse than 8-county mean (P = .002).
^bWorse than 8-county mean (P = .02).
^cWorse than 8-county mean (P = .04).
^dBetter than 8-county mean (P <.001).
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Figure 2
Ratio of Medi-Cal enrollee ED visits to new patient primary care access, by county.
ED = emergency department; Medi-Cal = California Medicaid.
Note: Multiple regression analysis adjusted for enrollee age and sex, and proportion of managed care enrollees. Circle sizes represent the number of Medi-Cal managed care enrollees in the county. There was an associated 5.9% (95% CI, 1.0%-10.8%) increase in enrollee ED visits (R2 = 0.47; P = .03) for each additional 100 enroll-ees lacking a regular source of care per available appointment.

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Table 1

Medi-Cal Enrollees and PCCs Contacted to Schedule Simulated New Medi-Cal Patient Appointments by County

County	Average Medi-Cal Enrollees, No.	PCCs Contacted, No.^a	PCCs in FQHCs, %	Contacted PCC Type, No.
County	Average Medi-Cal Enrollees, No.	PCCs Contacted, No.^a	PCCs in FQHCs, %	MD/DO	Physician Assistant	Nurse Practitioner
El Dorado	28,086	36	28	17	6	13
Placer	44,676	44	5	36	4	4
Sacramento	336,519^b	135	21	132	2	1
San Joaquin	132,867	66	27	66	0	0
Solano	107,641	104	23	78	13	13
Sutter	30,828	47	68	33	7	7
Yolo	50,473	123	15	75	27	21
Yuba	23,457	26	58	23	2	1
Total	754,547	581	25	460	61	60

DO = Doctor of Osteopathic Medicine; MD = Doctor of Medicine; Medi-Cal = California Medicaid; PCC = primary care clinician.
Note: 8 additional clinicians listed as accepting new Medi-Cal patient appointments could not be contacted (did not answer multiple telephone calls during business hours or telephone was disconnected).
↵a During a 2-month study period (July and August 2015).
↵b Excludes Medi-Cal enrollees in a closed-panel health maintenance organization, who were not included in the study.

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Table 2

Available Appointments With and Wait Times for Medi-Cal PCCs in 8 California Counties

County	Requested PCC, Any Appointment Available, %	Any PCC in Practice, Any Appointment Available, %	Any PCC in Practice, Appointment Available in ≤10 Days, %	Median Wait Time to Any Appointment, d
El Dorado	42	56	6	32.5
Placer	23	36	14	18
Sacramento	44	52	19	13.5
San Joaquin	50	70	36	7.5
Solano	25	36	10	18.5
Sutter	36	57	17	15
Yolo	24	76	20	7
Yuba	31	65	50	9
Total	34	56	19	12

FQHC = Federally Qualified Health Center; Medi-Cal = California Medicaid; PCC = primary care clinician.
Note: Data show combined adult and pediatric responses, as no difference in access was found between age-group scenarios. Clinicians were contacted in July and August 2015.

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The Article in Brief

Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study

Joy Melnikow , and colleagues

Background The expansion of Medi-Cal, California's Medicaid program, gave millions of low-income Californians access to health insurance. When new Medi-Cal enrollees have trouble getting a doctor's appointment, it is not uncommon for them to visit emergency rooms if they require more immediate care.

What This Study Found A study conducted in Northern California found that new patients may have to wait up to a month for an appointment with a participating primary care clinician, depending on their county of residence.This study looks at the variation between contiguous counties in the availability of new patient primary care appointments for Medi-Cal enrollees and at the correlation between primary care access and rates of Medi-Cal patients' emergency room usage. Researchers found that counties where it was more difficult to schedule new patient primary care appointments had higher rates of emergency room usage by Medi-Cal patients. Emergency room visits for concerns that would ordinarily be treated by primary care practitioners place a greater strain on already overburdened emergency departments and drive up health care costs overall. According to the study's authors, the data suggest that "adequate access to primary care will begin to improve health outcomes and control costs among beneficiaries of Medicaid expansion." Further studies would be needed to determine how California's challenges compare with those faced by other states that have expanded Medicaid eligibility under the Affordable Care Act.