Medicaid Patients and Healthcare Quality: Theory and Access

Introduction

Why are patients with Medicaid coverage not receiving the best quality of healthcare? One reason is that physicians do not want to participate in the Medicaid program because the rate of payment from either the state or the federal government is slower than even that of private insurance (Brabury, 2015). As a result, access to quality care is limited for individuals enrolled in Medicaid. Another problem is that evidence-based practice (EBP) approaches to quality care are less likely to be utilized by physicians and nurses in facilities that accept Medicaid patients, thus reducing the quality of care those patients receive (Calvin et al., 2006).

Medicaid patients also tend to have poorer health and come from poorer backgrounds, which puts them at an additional disadvantage from the outset, as their health needs are more complicated and their outcomes less favorable—factors that further impact the perception of care received (Sastow et al., 2019). Finally, patients with Medicaid tend to experience greater treatment delays than individuals who are privately insured (Naghavi et al., 2016). Grembowski, Cook, Patrick, and Roussel (2002) have analyzed the healthcare system from the perspective of exchange theory, which posits that the benefits and costs of an interaction between two parties are weighed to determine risks and benefits. Such an approach helps to explain why Medicaid patients receive lower-quality care. However, patient-centered care is an approach that should be adopted regardless of how care is paid for (Connole, 2012). An even better theoretical framework for explaining how and why quality care should be delivered to all patients—including those on Medicaid—is the Adaptation Model put forward by Roy (2018). This paper discusses the reasons Medicaid patients tend to receive lower-quality care from healthcare providers, what theoretical approach explains this phenomenon, and what theoretical approaches can be applied to help address this problem.

Lack of Physician Participation and EBP in Medicaid-Participating Facilities

Although the Affordable Care Act (ACA) was supposed to increase the number of people who could receive healthcare coverage from the government, a persistent problem remains: physicians do not want to participate in the program because payment for their services is delivered so slowly (Brabury, 2015). The reason for slow payment is partly bureaucratic and partly regulatory. The machinery of government is indeed cumbersome, but the government must also guard against fraud, as fraudulent claims represent a significant share of government payment requests. Because the government is slow to verify the validity of payments, physicians and facilities would prefer not to bear the negative impact this has on their cash flow.

There is also a lack of EBP among facilities that do participate in the Medicaid program (Calvin et al., 2006). EBP is important for providing quality care because it is based on the latest research developments, whereas older methods of treatment can rest on outdated concepts that are either no longer relevant or have been found to be ineffective over time. The problem is not that Medicaid-participating facilities are unaware of EBP; rather, it is that they often simply do not have the resources or funds needed to implement it.

Implementing new EBP means developing new protocols, policies, and guidelines; training staff on new approaches and standards; and developing measures, collecting data, evaluating outcomes, and reporting findings—a process that can be draining in terms of energy, time, and money. Facilities participating in the Medicaid program may already be tight on resources because of slow government payments. As facilities wait for state or federal funds, cash flow is suboptimal and budgets must be tightened year-round, especially when the number of Medicaid patients increases. These facilities tend to operate in a consistent, unchanged manner—deferring updates to procedures, tools, equipment, and policies until absolutely necessary—simply because change requires investment they cannot easily afford.

Health Status and Treatment Delays Among Medicaid Patients

A further challenge is that Medicaid patients frequently present with poor health and come from disadvantaged socioeconomic backgrounds. The more complicated their healthcare needs, the harder it is for Medicaid-participating providers to meet all of them (Sastow et al., 2019). When needs go unmet, it creates both the perception and the reality of low-quality care. Patients who are in poor health and from lower socioeconomic backgrounds tend to have a poorer overall experience with the healthcare system because that system was not designed primarily to serve them. The system is largely for-profit, and for-profit providers naturally direct their most attentive care toward the patients who sustain their business.

Treatment delays are an additional reason that lower-quality care is rendered to Medicaid patients (Naghavi et al., 2016). Naghavi et al. (2016) note several factors behind delayed treatment, including lack of access to care for underprivileged populations. When compared to individuals with private insurance, patients on Medicaid are less likely to gain timely entry to facilities and are less likely to be diagnosed or to receive the preventive care they need.

Conclusion

The healthcare system in the US does not adequately serve the needs of Medicaid patients. These patients tend to have complex health needs that drain a provider's time and resources without providing recompense sufficient to offset the costs of care. This creates a problem from an exchange theory perspective. Practically speaking, care providers do not want to be subject to a government regulatory agency that may deny payment because of an administrative error on the provider's part. The more reliable patient from a for-profit standpoint is the privately insured patient, which is why providers tend to locate and concentrate in communities where privately insured patients predominate. Access to care for Medicaid patients is therefore limited, and that limitation harms their health, delays their treatment, and reduces their odds of receiving quality care. Applying patient-centered care principles and Roy's Adaptation Model could help bridge this gap by reorienting care delivery toward the holistic needs of every patient, regardless of their insurance status.

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