MOJ ISSN: 2379-6383MOJPH

Public Health
Review Article
Volume 2 Issue 1 - 2015
Medicaid Reimbursement Fees and its Effect on the Provision of Care
Richard Blanco–Topping*
GIS Program Director, Loma Linda University School of Public Health, USA
Received:January 07, 2015 | Published: January 21, 2015
*Corresponding author: Richard Blanco-Topping, GIS Program director, Center for Leadership in Healthcare Systems, Loma Linda University School of Public Health, 24951 N, Circle Drive, Nichol Hall 1104, Loma Linda, CA 92350, USA, Tel: (909) 9653032; Email: @
Citation: Topping RB (2015) Medicaid Reimbursement Fees and its Effect on the Provision of Care. MOJ Public Health 2(1): 00009. DOI: 10.15406/mojph.2015.02.00009


The purpose of this project is to determine the effect of Medicaid reimbursement fees on physician practices. Related literature was accessed and incorporated in the document to provide information on the elements that affect physicians and Medicaid enrollees. For a better comprehension, a couple of studies with real examples are also provided for the reader. After analyzing the findings, it is clear that the Medicaid program does not satisfy physician’s expectations, as the fees are not enough to cover medical costs in the majority of the cases. Furthermore, research was conducted to address the challenges perceived by clinicians and consumers to identify potential solutions and the impact of such challenges on the quality of services offered by providers of Medicaid plans. The recommendations provided at the end of the document suggest a revision of the fees and the adoption of a model that benefits both physicians and patients alike.

Keywords: Medicaid; Reimbursement; Access to Care; Health Care Providers; Insurance


PACA: Patient Affordable Care Act; CMS: Centers for Medicaid and Medicaid; CHIP: Children Health Insurance Program; AIDS: Acquired Immunodeficiency Syndrome; NC: North Carolina


The selection of the research topic was to have an in-depth analysis of the U.S. health care reimbursement system; specifically, on the relationship between Medicaid services and their effect on the reimbursement process for physicians. In addition, it is interesting to acknowledge the role health care insurance plans play on the quality of care provided. As well, throughout the document both participants (physicians and patients) will be described to determine the factors that influence one or the other in order to provide valid recommendations that will be useful to maintain an appropriate service and create the required change. As George [1] indicated, the design of health system needs to change from a transactional attitude to a quality rewarding system. The latter applies to the entire industry, as patients are the main reason why health care services exist. That is, the Patient Affordable Care Act (PACA) focus should be characterized by influencing the level of care provided to patients. Moreover, while access to care is vital, the improved outcome should be a core focus.
Additionally, an explanation of the health care environment will be discussed to have a better idea of the effects of Medicaid patients on the service provided by physicians and health care organizations. The governing policies and their implication for the parties will outline some of the benefits and challenges that exist from deferent viewpoints. Not to end without a proposal on what actions may be necessary to improve the conditions, a number of recommendations are also provided with the intention to support the initiatives of access to care for low-income individuals, children, seniors, and disabled individuals. In addition, a number of potential activities that will enhance the quality of service for Medicaid patients and increase physicians’ participation in the government plan by adding incentives based on performance.


Medicaid History
This section will provide historical information on the inception of Medicaid and the main modifications that occurred with the program over the years. As Patrick and Freed [2] noted, they are changes in the national demography that influence Medicaid expansion. As the program was first created to provide insurance coverage for children, seniors and individuals with physical constraints in the poverty level, one of the main challenges in the provision of health insurance for qualified individuals is the reimbursement fee that physicians receive once the service is provided. Due to the low cost or no cost for low-income individuals, many have not taken advantage of the opportunity due to negative perceptions with public services [3].
The Centers for Medicaid and Medicaid (CMS) programs were established in the mid 1960s with the objective of providing health care insurance plans for low-income individuals. Two programs were created; Medicare and Medicaid, to serve populations that seek access to care, but did not have the means to satisfy such desire [2]. Since its inception, Medicaid has gone through many fundamental changes in order to continue to aid individuals with few resources. In addition, the expansion of Medicaid from children, seniors and individuals with limited physical mobility to incorporate a separate child coverage program named Children Health Insurance Program (CHIP) and patients with breast cancer and Acquired Immunodeficiency Syndrome (AIDS) is an example of the necessity of providing access to care to diverse populations.
As might be imagined, many factors impact the healthcare industry, including funding, enrolment and provision of care for Medicaid patients. In addition, despite the efforts to ensure low-income enrollees access to care there is a period in which a reduction in registration was noticed and the source for such behavior could be low reimbursement fees, restrictions to Medicaid plans and the creation of new rules to ensure efficiency [4]. Next, as the program faces many challenges there is a continuous effort by Federal, state and local governments to guarantee access to care under the Medicaid plan to millions of people who are seeking the services, but fell short for reason that are discussed further within the document.
Since Medicaid is a government and state funded program the challenge is to continue to provide services or plans for individuals that comply with the requirement in times of economic distress [2]. Therefore, in tough economies programs suffer from a lack of funding, services are reduced based on a limited amount of resources, mainly financial and personnel availability. According to Adams and Herring [4] the main concern for Medicaid program is to increase access to physicians’ offices; due to little compensation or low reimbursement fees, many physicians are reluctant to accept patients that are part of the program. Moreover, another factor that complicates the Federal and state efforts to increase enrolment and attention is the accessibility to physicians or hospitals facilities from poor communities to locations with higher socioeconomic status. The latter is a challenge that poorest neighborhoods encounter, due to their low-income status. Consequently, as mentioned by Adams and Herring [4], the inclusion of Medicaid enrollees into health maintenance organization between the years of 1990 and 2000 was a strategy to augment more enrollees to doctors’ offices.
Another is the challenge to fund different programs when there are changes in the demography [2]. The main reason the Medicaid program was created in 1965 was to protect children by providing a safe and healthy environment. Overtime, such conditions changed. During the inception of the program, the percentage of children in the nation was almost 40%, while during the mid 2000s that percentage decreased to just over 24%. Therefore, such numbers justified a shift in funding under the Medicaid program and the creation of additional legislation to support the delivery of care for seniors.


  1. Voorhees J (2014) Everything That Went Wrong in Dallas.
  2. Centers for Disease Control and Prevention (CDC) (2014) Enhanced Ebola Screening to Start at Five U.S. Airports and New Tracking Program for all People Entering the U.S. from Ebola-affected Countries. Centers for Disease Control and Prevention, USA.
  3. Ferris S (2015) With no new Ebola cases, CDC lifts travel restrictions in Mali. THE HILL, USA.
  4. Paddock C (2015) US Lifts Ebola Screening for Travelers from Mali. Medical News Today, USA.
© 2014-2018 MedCrave Group, All rights reserved. No part of this content may be reproduced or transmitted in any form or by any means as per the standard guidelines of fair use.
Creative Commons License Open Access by MedCrave Group is licensed under a Creative Commons Attribution 4.0 International License.
Based on a work at
Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version | Opera |Privacy Policy