Medicaid and CHIP Risk-Based Managed Care in 20 States. Experiences Over the Past Decade and Lessons for the Future.. Provider Shortages.


We asked state officials, plans, and provider representatives whether they perceived provider shortages or excess provider capacity and of what type. In five states (Florida, New Jersey, Texas, Virginia, and Washington), we consistently heard of shortages from all three types of informants, while in other states there was less consistency. Indeed, some informants commented on the need for more accurate information on this important topic.

When there are shortages, states have devised various strategies to expand the number of providers participating in MCO networks. Several states reported on their efforts to use mid-level practitioners to enhance the supply of PCPs in geographic areas with shortages of PCPs, such as rural areas.

We’ve been using more physician extenders—nurse practitioners—in the rural areas. It’s been more prevalent now than ten years ago. (Plan Representative)

However, state licensing laws determine whether the scope of practice for nurse practitioners, physician assistants, or nurse midwives allows them to be a PCP.

The state has mandated more practice rights for physician extenders like nurse practitioners and physician assistants. (Plan Representative)

The model that we believe works best is physician-led primary care practice where mid-levels, including nurse practitioners and physician assistants, practice as part of an enabled team. We do have nurse-managed sites in our program, and the ones we have do extremely well, so we believe that that’s an additional capacity that we’re going to need going forward to 2014. (Plan Representative)

This latter comment reflects a heightened awareness of the potential for provider shortages— particularly PCP shortages—with the implementation of the Affordable Care Act. At the same time, there is some evidence that new providers are participating in Medicaid managed care in anticipation of the changes in 2014.

There are some reasons why a doctor or a hospital might say "Wow, I’d prefer not to work with Medicaid but maybe I should." (Plan Representative)

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