Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid

Abstract

Understanding the extent to which beneficiaries can "realize" access to reported provider networks is imperative in mental health care, where there are significant unmet needs. We compared listings of providers in network directories against provider networks empirically constructed from administrative claims among members who were ages sixty-four and younger and enrolled in Oregon's Medicaid managed care organizations between January 1 and December 31, 2018. "In-network" providers were those with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a given health plan. They included primary care providers, specialty mental health prescribers, and nonprescribing mental health clinicians. Overall, 58.2 percent of network directory listings were "phantom" providers who did not see Medicaid patients, including 67.4 percent of mental health prescribers, 59.0 percent of mental health nonprescribers, and 54.0 percent of primary care providers. Significant discrepancies between the providers listed in directories and those whom enrollees can access suggest that provider network monitoring and enforcement may fall short if based on directory information.

EXHIBIT 2. Proportion of plan directory providers that were listed and accessed versus not accessed, or “phantom,” in Oregon Medicaid, by coordinated care organization (CCO), 2018

SOURCE Authors’ analysis of 2018 Medicaid managed care health plan provider directory files and Oregon Medicaid claims data. NOTES This exhibit shows the proportion of all directory-listed providers (primary care providers, specialty mental health prescribers, and nonprescribing mental health specialists; see the text for provider types in each group) that fall into the following categories: a health plan listed a provider in their directory and the provider saw the coordinated care organization’s patients in the claims data (“listed and accessed”); or a health plan included a provider in their provider directory, but the provider did not see that coordinated care organization’s patients in the claims data (“listed but not accessed,” or “phantom” providers). CCOs are Oregon’s Medicaid managed care organizations; they are deidentified to preserve anonymity for individual organizations.

EXHIBIT 3. Percent of providers accessed versus Medicaid panel sizes for different provider network types in Oregon, by coordinated care organization (CCO), 2018

SOURCE Authors’analysis of 2018 Medicaid managed care health plan provider directory files and Oregon Medicaid claims data. NOTES This exhibit shows CCO-level plots of “realized access” versus Medicaid panel sizes for different provider network types (primary care, mental health prescribers, and mental health nonprescribers). “Realized access” was defined as the percent of providers in the provider directory files who were also in network based on claims (that is, a ratio of in-network providers by claims to total providers reported in the directory files). Each data point represents a CCO (Oregon’s Medicaid managed care organizations). To calculate Medicaid panel size, we identified total patients from the member cohort for which providers had claims during the study year and then computed a median for each CCO. The dashed lines represent the average median panel size and percent of providers accessed across all CCOs.

EXHIBIT 4. Comparison of realized access across coordinated care organizations (CCO)s in Oregon Medicaid managed care, for mental health providers versus primary care providers, 2018

SOURCE Authors’analysis of 2018 Medicaid managed care health plan provider directory files and Oregon Medicaid claims data. NOTES This exhibit presents a comparison of “realized access” across provider types. Each data point represents a coordinated care organization (CCO), Oregon’s Medicaid managed care organizations. “Realized access” is defined in the exhibit 3 notes. Any dot on the dashed “Parity” line represents a CCO with parity in realized access between primary care and specified groups of mental health care providers (specialty mental health prescribers and nonprescribing mental health specialists).