Nearly one-third of physicians enrolled in Medicaid are not providing care to any Medicaid patients, according to new research led by Oregon Health & Science University (OHSU). The study, published today in the journal Health Affairs, highlights significant gaps in a program that serves nearly 80 million Americans.
The research also indicates that another third of Medicaid-enrolled healthcare providers are seeing a high volume of patients—over 150 annually—potentially leading to provider burnout. These findings suggest that enrollment data alone may not accurately reflect the actual availability of healthcare services for Medicaid recipients, a program primarily serving low-income, disabled, and young Americans.
“Low physician participation in Medicaid is a commonly cited reason for access gaps and unmet need in Medicaid,” said Dr. Jane Zhu, the study’s lead author and an associate professor of medicine at OHSU. “If patients aren’t able to access the care they need, they may delay or forego care altogether, which is not only bad for patient outcomes, but also bad for the health system overall.”
Unpacking the “Ghost” Provider Phenomenon
Researchers analyzed administrative claims data and provider enrollment across five key physician specialties: primary care, psychiatry, cardiology, dermatology, and ophthalmology. They discovered that actual participation in Medicaid was significantly lower than enrollment numbers suggested. The issue was particularly acute in psychiatry, where over 40% of psychiatrists listed as Medicaid providers did not see any Medicaid patients throughout the year.
These non-participating physicians are referred to as “ghost” providers. The study’s findings echo a previous investigation in Oregon’s Medicaid program, indicating a nationwide issue.
“Patients may call providers who say they are enrolled in Medicaid, but those calls go nowhere,” Zhu noted. “People give up because those providers aren’t actually available to see them.”
Understanding the Implications
This discrepancy in provider availability raises the risk of poor health outcomes and increased healthcare costs. When patients delay or forego necessary care, they often end up with more severe health conditions that are costlier to treat. Dr. Zhu emphasized the importance of assessing the real-world experiences of patients who struggle to access healthcare providers, rather than relying solely on enrollment statistics.
“Maintaining access to care is a really big problem with increasing demand for services and workforce shortages,” Zhu said. “A clearer picture would help policymakers better spend public dollars on levers that meaningfully impact provider participation.”
Policy and Research Recommendations
The study utilized Medicaid claims data from the Transformed Medicaid Statistical Information System Analytic Files, covering the years 2019 through 2021. The research was supported by the National Institute of Mental Health and involved collaboration with experts from Johns Hopkins University.
To address these issues, policymakers are encouraged to consider strategies that go beyond enrollment figures to improve actual patient access to care. This includes investing in initiatives that enhance provider participation and reduce barriers for Medicaid patients seeking care.
The study’s co-authors, including Kirbee Johnston, Kyle Hart, and John McConnell from OHSU, and Daniel Polsky from Johns Hopkins, underscore the need for comprehensive reforms to ensure that Medicaid can effectively serve its intended population.
As the healthcare landscape continues to evolve, addressing the “ghost” provider phenomenon is crucial to maintaining a functional and equitable Medicaid system. By focusing on real-world patient experiences and provider engagement, the program can better fulfill its mission of delivering quality healthcare to millions of Americans.
