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Obamacare To Pressure Californians’ Access To Medi-Cal Doctors

First in a series of occasional articles about the Affordable Care Act.

In less than one year, Obamacare’s promise to bring health care to perhaps 1 million more poor California residents will be tested.

The big day arrives Jan. 1, 2014, when Medi-Cal, a publicly funded health program for low-income and disabled residents, launches a huge statewide expansion.

But making a promise is one thing, and delivering is another.

In some places, it’s already difficult for many poor California residents to find a doctor who is able – or willing – to see them when they need one.

From the Bay Area to San Diego, from the sprawling Los Angeles basin to the sparsely populated rural north, many medical providers who currently see these patients say they are overwhelmed, a situation that could worsen when those newly covered by Medi-Cal arrive for care.

The epicenter is California’s Central Valley, where high rates of uninsured residents, coupled with persistent doctor shortages, create a potentially combustible brew that could thwart the success of the health care law.

“We’re not even talking about 2014,” said Carmen Burgos of the nonprofit Greater Bakersfield Legal Assistance program. Burgos helps low-income Kern County residents access health care and dental services. “Good luck finding a doctor who takes Medi-Cal now.”

Progam Expansion

More than 7 million Californians are covered under Medi-Cal, and expanding the program is a major piece of President Obama’s signature health law, called the Affordable Care Act.

Between 2014 and 2019, roughly 1 million to 1.4 million more Californians will enroll in Medi-Cal as a result, according to UCLA and UC Berkeley estimates.

The Medi-Cal expansion will broaden eligibility by allowing applicants with higher incomes and allowing those who were previously ineligible, such as childless adults, to get coverage.

State officials say that there’s sufficient access to Medi-Cal services and that they are constantly monitoring to ensure that recipients can get care.

“We do believe that the Medi-Cal provider network provides adequate access in California now,” said Norman Williams, spokesman for the state Department of Health Care Services, which administers Medi-Cal. The state also is “adequately preparing for 2014 and the expansion.”

But doctors and health care experts across the Golden State offer a starkly different portrait of access on the ground.

“We’re experiencing provider shortages right now,” said Alex Briscoe, director of the Health Care Services Agency in Alameda County, home to the cities of Oakland and Berkeley.

He sees pressure points across the entire county, from less-populated areas to denser communities. “Patients often wait months to get access to care,” he said.

Desperate parents overwhelm phone lines at Riverwalk Pediatric Clinic, a private practice in Bakersfield, searching for doctors who accept Medi-Cal, said pediatrician Hasmukh Amin. About half of the practice’s 20,000 patients already have Medi-Cal.

“We say no to 25 to 30 callers per day,” Amin said. “We cannot handle any more volume. We are maxed out.”

In Los Angeles County, more than 1 million people – about one-third of them on Medi-Cal – were seen at 174 health clinics in 2011, said Louise McCarthy, president of the Community Clinic Association of Los Angeles County. When asked whether there will be enough doctors to serve the growing population of Medi-Cal patients, she replied simply, “No.”

Low Rates

Medi-Cal is California’s version of the federal Medicaid program, and the Golden State ranks poorly in doctor participation compared with other states.

Two studies, including one published in the journal Health Affairs in August, show that 57 percent of California doctors accept new Medi-Cal patients. That’s the second-lowest rate in the nation after New Jersey.

California’s neighbors, Nevada and Oregon, accept 75 percent and 80 percent, respectively.

The primary reason doctors don’t participate is financial, doctors themselves say.

Here, too, California scores badly, with one of the nation’s lowest payment rates, ranking 47th of 50.

“I would challenge any legislator, any politician … to come to my community and see if a Medi-Cal patient can get the access to the care they need when they need it, without going to the emergency room,” said Ted Mazer, an ear, nose and throat specialist in San Diego.

Mazer chairs the California Medical Association’s committee that focuses on Medi-Cal policy. The association represents more than 35,000 doctors in the state.

He said doctors lose money providing care under Medi-Cal. For example, he said, Medicare, the federal health insurance program for people 65 and older, pays doctors about $76 for a regular, return office visit. One private insurance company pays about $71.

Medi-Cal? It pays $24, he said.

About six years ago, Mazer began limiting his participation in the program.

Low Medi-Cal rates are being addressed — temporarily at least — by Obamacare.

Starting this past January and lasting two years, reimbursement rates for many primary care services in Medi-Cal will jump to Medicare levels, funded by the federal government.

In California, the change is dramatic. On average, fees will increase by 136 percent, according to the Kaiser Commission on Medicaid and the Uninsured.

“The payment increase is a significant incentive that we anticipate will help attract new primary care physicians to the Medi-Cal provider network,” said Williams of the Department of Health Care Services.

But improving access to care will involve more than convincing more doctors to participate, said Linette Scott, the department’s chief medical information officer.

It will be about changing the way care is delivered, she said. As the state moves more Medi-Cal recipients into managed care, she said, models of treatment will rely more on teams of health professionals to care for patients, not just individual doctors.

Plus, health plans must ensure there are enough doctors and other medical providers in their networks to provide that care, Williams said.

“You don’t have to go door-to-door or through the phone book to find your provider,” Williams said. “The managed care plan assigns you a primary care physician. It helps facilitate your care.”

Lack of Choices

In some communities, many Medi-Cal patients have no other choice than clinics, said Debbie Wood, coordinator of school health for the Bakersfield City School District, where nearly 90 percent of students live at or below the poverty level.

“They go to the clinics and they sit there for six, seven, eight hours. They may have an appointment at 8 a.m. and not be seen until 4 in the afternoon,” she said.

While patients ultimately receive care at the clinics, they pay for the crowded conditions in other ways, Wood said.

“Many of our families are in agricultural work,” she said. “If they miss a day they don’t get paid. So they go to the emergency room.”

McCarthy, of the Los Angeles County clinic association, said clinics are working double-time to hire more doctors and increase capacity, but isn’t sure if their efforts will be enough.

“At a certain point, the clinics are going to need to say ‘I need to cap enrollment or cap my patient load’,” she said. “It’s critical we take on new patients in a sustainable manner.”

The CHCF Center for Health Reporting is an independent news organization that reports about health care issues. It is based at the University of Southern California's Annenberg School for Communication and Journalism and funded by the non-profit California HealthCa

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Avatar for user 'mohammad ashori'

mohammad ashori | March 4, 2013 at 10:11 a.m. ― 4 years ago

As a physician I am not protected if I decide to work in a town that has that kind of an underserved group of patients. I would actually be exposing myself to increased medical-legal risk. I would have to see more patients, with higher complexity, make less income, manage patients with lower education which translates to higher noncompliance and be at higher risk for law suits. I have to constantly worry about whether my chronic pain patient is abusing the drugs I am giving them, I have worry about my female patients trying to claim sexual misconduct, I have to deal with specialists who may not decide to treat the disease that I diagnosed due to poor compensation.....and the list goes on. This partly fueled by the thousands of patients who sue doctors for errors and partly because there is no protection offered to the physicians that have a great track record. Every day when I go to work it could be the last day that I practice. That 55 year old female that had that innocent cough could have had a pulmonary embolism, I decided not to send her to the ER because she didn't clinically appear to have a PE, she didn't have transportation to the ER, the ambulance would have charged her $500+, it would have been impossible to get her a CT scan of the chest outpatient and even if I did decide to send her she may not have felt the sense of urgency. If I'm expected to be the parent, the organizer, orchestrator, the resource organizer, the lackey, the scapegoat and the healer then I expect something else in return than what's being offered right now.

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Avatar for user 'JeanMarc'

JeanMarc | March 4, 2013 at 10:37 a.m. ― 4 years ago

Well said mashori. If I were a doctor, I would be hesitant to accept medical patients. Who has medical? Poor people. Why are people poor for the most part? Because they made poor choices, because they have poor reasoning skills, etc. Working with them would be a liability for sure.

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Avatar for user 'benz72'

benz72 | March 4, 2013 at 11:44 a.m. ― 4 years ago

"Starting this past January and lasting two years, reimbursement rates for many primary care services in Medi-Cal will jump to Medicare levels, funded by the federal government."

So what happens in two years? Will reimbursement rates return to normal? Does CA expect to keep taking federal funds beyond that timeline?
If a doctor accepts a patient for those two years and the rates go down, can he drop them since there is no longer adequate funding?

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Avatar for user 'csmith1982'

csmith1982 | March 4, 2013 at 12:25 p.m. ― 4 years ago

I agree to an extent JeanMarc. Yes a good majority of the people are on medical because of being poor or making poor choices but then there are plenty like me who have been laid off. I was laid off in September from the university I was working at due to restructuring of the company. 450 people were laid off the same day I was and my husband was laid off in August from the Law office he worked at due to a shortage in cases. We are educated with degrees and have extensive work experience. My family is on medical because we have no choice but to be. More and more situations like mine will be coming to medical as the job market is not so kind right now. I was actually told by one company that I have too much expertise for the position I applied for. When you just want a job is that a fair statement to give someone? Keep this is mind as you talk about teh people who are on medical there are those of us who are actively searching daily for work and do not actually wnt to be on medical but have n choice if they are going to get their kids taken care of.

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Avatar for user 'DeLaRick'

DeLaRick | March 4, 2013 at 1:43 p.m. ― 4 years ago

Dr Mashori,

It sounds as if being a physician is nothing but a pain. If you could only do away with those pesky patients (aka resource drainers) ...

If everyone lived perfect lives or could heal themselves, society wouldn't need you.

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Avatar for user 'JeanMarc'

JeanMarc | March 4, 2013 at 3:09 p.m. ― 4 years ago

csmith, I sincerely hope you have better luck finding employment. It is very difficult, and sometimes I do forget that there are people like you and your husband who actually want to work instead of sit around seeing how many benefits they can get.

I have heard of people being turned down for jobs because they were over-qualified and it does seem absurd to me.

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Avatar for user 'mohammad ashori'

mohammad ashori | March 9, 2013 at 9:51 a.m. ― 4 years ago

Being a physician is one of the most rewarding, fulfilling and enjoyable things I could imagine myself doing. I am very grateful and humbled that another human being puts their health in my hands and allows me the honor to help heal them. But just like anything beautiful in life it does have the other side, the monetary side. In order for me to be around for those patients of mine who genuinely want medical care I have to navigate around those who disregard their health and tip toe around the laws that could bring my career to an end.

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Avatar for user 'CaliforniaDefender'

CaliforniaDefender | March 9, 2013 at 12:56 p.m. ― 4 years ago

I completely agree with Mashori and wouldn't blame a doctor for not accepting low-income Medical/Obamacare patients. They are far too risky.

In fact, I would prefer a doctor that does not accept Medical/Obamacare patients at all. Such a doctor would be more likely to concentrate on practicing medicine rather than law and that will keep me healthier.

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