Public and Private Payer Reimbursement Rates for Office Visits

How much do visits to the doctor cost for adults with various sources of payment for those visits?  Researchers writing in Health Affairs attempt to answer this question.   (HA Article)  They used Medicare Expenditure Panel Survey records for adults aged 18 to 64 and supplemented that with actual physician office billing records.  They compared total payments (those by the third-party payer and by the individual patient) for people with Medicaid, employment-based, exchange individual and non-exchange individual coverage.  The data came from 2014 and 2015 and covered over 30,000 visits, of which 7500 were preventive, about 9000 were other primary care visits and 14,000 were to specialists.  The average total payment for Medicaid preventive care visits was $106, which was about 63% of the average payments covered by employer plans, at $168.  Exchange plans averaged $176 for a preventive visit payment and non-exchange individual coverage averaged $174.  If Medicare had paid for the visits and its reimbursement rates used, the average payment would have been $143.   Specialist visit payments followed a similar pattern, although Medicaid reimbursement was only 52% of those for employment-related coverage.  Total average payments under Medicaid were 74% of what Medicare would have paid, whereas employer plans paid about 118.5% of those amounts.  The out-of-pocket share for patients with employer coverage were much higher than for Medicaid patients.  Exchange and other individual plans also had higher out-of-pocket share of total visit costs.

One implication of the study is that the cheapest way to expand coverage, if you think that is a worthy public policy goal, is to put people on Medicaid, not use the exchanges.  But there is a limit to what physicians will accept and large numbers either accept no Medicaid patients or won’t take new ones, creating access issues.  It is unlikely that physicians cover their costs with Medicaid reimbursement, resulting in higher charges to privately-insured patients and perhaps even Medicare.  There may be quality implications as well.  Some states and advocates for the poor, wanting to extend the lunacy of current health reform trends, have suggested that doctors be forced to take Medicaid patients.  Raising Medicaid reimbursement would be financially difficult for most states, which are already floundering under the weight of Medicaid spending.  But if Medicaid enrollment were restricted to those who truly need it, and recipients were required to engage in healthy behaviors or lose their coverage, enough savings could be achieved to raise payments.