March 17, 2017
Area(s) of Interest: Access to Care
California’s communities face a severe shortage of physicians, which is expected to get exponentially worse as the population continues to grow and our aging physician workforce moves toward retirement.
Medi-Cal enrollment has surged since 2014, but the percentage of California physicians serving Medi-Cal patients has dropped, a trend that is hampering access to care for enrollees. One in every three Californians (14.3 million) is dependent on Medi-Cal for health care, so this disparity also negatively impacts a patient’s ability to access needed treatment, according to a recent study by the California Health Care Foundation.
There is a fundamental problem with Medi-Cal that is hindering patient access to care, and to specialists in particular – Medi-Cal physician reimbursement is so low that physicians cannot cover the cost of providing care. Currently, California has some of the lowest reimbursement rates for providers ($18 for an office visit), creating an unsustainable disparity between the number of Medi-Cal patients and the physicians who are able to accept them as patients.
"Specialists are paid so poorly that they don't want to take Medi-Cal patients," said Mark Dressner, M.D., a Long Beach clinic family physician and former president of the California Academy of Family Physicians. "We're really disappointed and concerned with what it's going to do for patient access."
The volume of poor and uninsured patients that need to see specialists has overwhelmed the health care system in Los Angeles causing appointment delays.
Dr. Dressner says he is extremely frustrated with the problem. “If I have patients that need a rheumatology consultation, it can take two years for them to get an appointment,” he explains. Some of his patients have to travel over 50 miles to see specialists who will take Medi-Cal because none of the specialists in the immediate area will.
Not only are physicians frustrated with the lack of access to care, the patients themselves are frustrated with their treatment. Barbara Appling, a 56-year-old diabetic, was referred to an orthopedist in the Los Angeles area near her home.
“I called the office repeatedly for an appointment. It took four months to get one. Then, when I went to the office, I was there for 40 minutes waiting to be seen – until the office manager told me they could not see me.” Appling has both Medi-Cal and Medicare insurance. The office staff member told her the doctor didn’t take either.
“I’m very frustrated that I cannot see a doctor when I need to. People have refused to take Medi-Cal since I got it,” she said. Due to low Medi-Cal reimbursement rates, physicians who see Medi-Cal patients often do so at a financial loss to their practices. In order to maintain viable practices that can continue to serve their communities, physicians who take Medi-Cal often need to limit the number of Medi-Cal patients that can be treated in their practice.
Because they do not have ready access to physicians, Medi-Cal patients are more likely to postpone needed care due to long appointment wait times. They are also twice as likely to use emergency room visits to access specialty care (compared to individuals with private insurance or Medicare).
In areas where the numbers of specialists are low, physicians are more likely to report difficulty obtaining referrals for Medi-Cal patients than for privately insured patients.
Debra Lupeika, M.D., a family physician providing care through the Shasta Community Health Center in Redding, says some of the most difficult issues she faces are getting her sickest patients referrals to specialty providers.
The frustration of not being able to refer wears on her – like the time her patient suffered without an appointment. “She had complicated medical problems, and she was homeless,” Dr. Lupeika says. “She had a cancer on her face that had been partly removed, but it came back. We couldn’t get a biopsy. It is really hard to get our patients into specialist due to insurance issues.”
Lack of access to specialists also plagues San Diego County.
“The challenge that we face is that reimbursement to physicians is the third-lowest in the country. So that limits access to specialty care,” says Patrick Tellez, M.D., MPH, a pediatric allergy and immunology specialist and Chief Medical Officer for North County Health Services, which provides health care to a diverse community of low-income patients at 13 health centers in North San Diego and Riverside counties.
“Our mission, as a primary medical, dental and behavioral health practice attending to over 65,000 patients annually, is to assure that our patients are able to access and receive needed primary and specialty care that meets the high standards that everyone of us expects when we are the patient," says Dr. Tellez. "However, when the reimbursement for specialty care is so low, specialists can only afford to accept a small percentage of patients that truly need and deserve the care."
"So, while in an average month we as primary care providers may make about 2,500 or more referrals to specialty care, due to affordability, wait times and constrained access, less than half are able to be seen. As a result, this has the long-term adverse impact of increasing the cost of care for everyone. Improving access to specialty care has been shown to help prevent preventable complications of chronic disease, which lowers the long-term cost of care…it acts like a rising tide that floats all boats.”
Of California’s 58 counties, Merced County has the 43rd worst physician-to-patient-ratio, with just 45.4 family physicians per 100,000 residents. That’s far less than California’s statewide ratio of 77.3 doctors per 100,000 residents. According to the Merced County 2016 Community Health Assessment, the entire county is considered a health-professional shortage area.
Eduardo T. Villarama, M.D., family physician and regional medical director of Golden Valley Health Centers in Merced, says he is aware of many instances when patients who needed to see a specialist were turned away. “We have more than 70 percent Medi-Cal patient population, and specialty care providers regularly turn them away or are not able to accommodate the demand because the specialists are not reimbursed appropriately.”
He says a few of his patients, “one with seizure disorder and the other we suspect to have multiple sclerosis,” have had to wait for at least six months to be seen by a specialist in neurology. “I know for a fact that the patients being insured by Medi-Cal played a role in our abilities to get them in sooner.”
Ample research demonstrates that the Medi-Cal system is struggling from chronic underfunding. Last year, the California Medical Association (CMA) co-sponsored the Proposition 56 tobacco tax to raise money to improve access to and quality of medical services for all Californians – especially our most vulnerable communities who rely on Medi-Cal.
The language was clear – tobacco tax revenues must be used to increase access to health care by providing improved payments for treatment and services. However, Governor Jerry Brown's $120 billion budget proposal for the 2017-18 fiscal year takes $1.2 billion of the Prop. 56 tobacco tax money to cover existing state budget obligations in Medi-Cal.
With 14.3 million Californians – and 50 percent of all the state’s children – relying on Medi-Cal programs to provide basic and specialty care for serious diseases, the stakes are high.
The Governor’s proposed budget simply adds more patients to the back of the line and maintains the status quo, which does nothing to help patients gain needed access to doctors and dentists.
“People voted overwhelmingly in support of improving payments for programs and providers to ensure that patients can see a doctor when and where they need one,” says CMA President Ruth Haskins, M.D. “We must honor the will of the voters and use the estimated $1.2 billion in new health care revenue for its intended purpose, instead of writing a blank check to the general fund.”
CMA and the California Dental Association are calling on the legislature to uphold the will of Prop 56 voters and use the tobacco tax revenues to increase Medi-Cal patient access to doctors and dentists. Our plan strengthens Medi-Cal and Denti-Cal, which will lead to healthier patients and long-term financial savings to the state.
Serve Medi-Cal patients? Please send your experience and perspective to firstname.lastname@example.org. CMA wants to highlight the access to care challenges facing you, your patients and community.