Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study

Ann Fam Med. 2020 May;18(3):210-217. doi: 10.1370/afm.2502.


Purpose: We undertook a study to evaluate variation in the availability of primary care new patient appointments for Medi-Cal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion.

Methods: We placed simulated calls by purported Medi-Cal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of Medi-Cal managed care plans. Data from the California Health Interview Survey, Medi-Cal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county.

Results: Availability of PCC new patient appointments to Medi-Cal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by Medi-Cal enrollees.

Conclusions: In contrast to findings from other states, access to primary care in Northern California was limited for new patient Medi-Cal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by Medi-Cal enrollees.

Keywords: Medicaid expansion; Patient Protection and Affordable Care Act; United States; barriers; health; health services accessibility; insurance; national health insurance; practice-based research; primary care access; secret shopper; simulated patient; vulnerable populations.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Appointments and Schedules*
  • California
  • Child, Preschool
  • Female
  • Health Services Accessibility / legislation & jurisprudence
  • Health Services Accessibility / statistics & numerical data*
  • Humans
  • Male
  • Medicaid / legislation & jurisprudence
  • Medicaid / statistics & numerical data*
  • Patient Protection and Affordable Care Act
  • Patient Simulation
  • Primary Health Care / legislation & jurisprudence
  • Primary Health Care / statistics & numerical data*
  • United States