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Research Questions

  1. What were the key implementation challenges during the rollout of the policy from the perspective of all relevant stakeholder groups?
  2. How did stakeholders view the impact of the policy, and what were the key factors associated with perceptions of success and lack of success of the policy?
  3. Which states elected to continue the payment increase policy in the absence of full federal funding? Why? Among states that did not continue the policy what was the rationale for their decision?
  4. What strategies would stakeholders recommend to improve the implementation of similar policies in the future?

Between January 2013 and December 2014, the Affordable Care Act authorized enhanced payments for qualifying providers of primary care services participating in the Medicaid program that would be funded entirely by federal dollars. The purpose of the policy was to encourage provider participation in Medicaid prior to and during the expansion of the Medicaid program that began in January 2014 in many states. To better understand differences in approaches and the potential challenges in implementing the policy from the perspective of Medicaid officials, providers, patients, and health plan administrators, the Office of the Assistant Secretary for Planning and Evaluation commissioned the RAND Corporation to conduct an independent case study into stakeholder experiences before, during, and after the policy's implementation in nine states.

Implementation of the policy was challenging. The policy's short planning time line limited the amount of time that states and key stakeholders had to determine eligibility, develop eligibility attestation systems, and adapt or create new payment systems. Payments were initiated late in all states. Stakeholders overwhelmingly viewed a temporary payment increase lasting only two years as insufficient to encourage clinics to make investments needed to join Medicaid or expand capacity. Stakeholders in some states reported that physician participation in the Medicaid program was already high, and no efforts were made to engage nonparticipating physicians, which might also have blunted the policy's impact. Stakeholders identified the need for adequate planning and preparation, clearer guidance from rulemaking authorities, and greater state flexibility in the design of future similar payment policies.

Key Findings

High Provider Participation Rates in Medicaid Pre-Implementation

  • For most states, primary care provider participation was generally viewed as high preceding the policy.
  • Providers who decline to participate in the Medicaid program tend to do so because of low reimbursement rates, administrative difficulties, and challenges associated with caring for Medicaid patients.

Implementation Complicated by Limited Time Line

  • States did not receive final guidance until two months before the policy was supposed to begin and additional clarification was required subsequently. This delayed states' ability to provide attestation guidance to providers, which, in turn, delayed states' and MCOs' efforts to configure claims-processing systems and initiate payments.

Implementation Challenges Posed by Provider Eligibility Criteria and Attestation Processes

  • A large number of physicians who met the eligibility criteria viewed themselves as specialists rather than primary care physicians.
  • Several respondents suggested that the eligibility criteria failed to reflect the way primary care was delivered in many states — particularly by excluding advanced practice nurses.

No Formal Evaluations Conducted by State-Level Stakeholders; Perception of Limited Impact

  • Most respondents indicated that the policy had, at best, a modest impact on incentivizing higher rates of provider participation.
  • Respondents in most states noted that increased payments over a span of only two years did not provide a potent incentive for physicians to make investments needed to expand their participation in Medicaid.

Patients and Providers Realized Benefits

  • Most respondents suggested that the program was beneficial and helped keep Medicaid providers "afloat" for the duration of the policy.


  • Additional lead time would help states to ensure that policies and procedures critical to program function are in place before launch and reduce the need to retool or revise midstream.
  • Clearer eligibility requirements could ensure a rapid start to the program.
  • Given the complexities of the policymaking and implementation environment, clear, bidirectional communication with key stakeholders is important to ensure a smooth implementation process.
  • By performing targeted outreach to stakeholders who fall outside of existing communication channels or stakeholder groups (e.g., primary care providers not currently enrolled in Medicaid), states may be able to expand program participation.
  • Web-based attestation forms that are securely and centrally collected could reduce administrative burdens on providers.
  • The need to make payments retroactively or to recoup monies that were improperly disbursed and the protracted period over which providers were able to attest, places a large burden on the state, MCOs, and providers. Properly sequencing eligibility determinations and the initiation of enhanced payments and ensuring that they align with a policy's start date would substantially lower the burden on all stakeholders.
  • Many respondents urged CMS to allow for more flexibility in implementing similar payment policies that better reflect the primary care delivery system in the state and that are complementary with other ongoing payment and delivery reforms.
  • Respondents reported that health care providers would have been more inclined to make investments to expand their participation in Medicaid had the federal government provided full funding for a period longer than two years.

This research was conducted by RAND Health.

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