News In Numbers: For One In Three San Diegans, Finding A Doctor Is An Ordeal
Voter-approved tobacco tax may provide some relief
Monday, January 2, 2017
Photo by Megan Wood / KPBS
San Diego surgeons and specialists are the least likely in California to accept Medi-Cal patients, a population that ballooned in San Diego under the Affordable Care Act.
If you’re a Medi-Cal patient, getting a timely appointment with a doctor has never been easy. But two statewide reports say that for San Diego beneficiaries, whose numbers have increased 22 percent in two years, it’s especially tough.
That’s because primary care doctors here are less likely to accept new Medi-Cal patients than in most other regions in the state. Local surgeons and specialists, such as gastroenterologists and orthopedic surgeons, are the least likely.
Janet Coffman, a researcher at the University of California, San Francisco’s Institute for Health Policy Studies and the author of two foundation reports on the subject, emphasized the problem is worse in San Diego.
“You have many, many people competing for an appointment with the same physician,” she said. “That’s a concern because for some diseases and conditions, time is very important; people need to see a physician as soon as they can.”
Twelfth largest city
The shortage of doctors willing to treat Medi-Cal patients is exacerbated here because of the sheer numbers of beneficiaries.
Nearly 1 million San Diegans, almost three in 10, are enrolled in the program, which pays for care for people with incomes below 138 percent of the federal poverty level. That’s equivalent to a population that would make up the 12th largest city in the country.
Other regions also face a shortage of Medi-Cal doctors, especially since California expanded Medi-Cal eligibility under provisions of the Affordable Care Act. That added 3.8 million enrollees, bringing the total to more than 13 million statewide.
But Coffman’s 2014 report on the issue said the San Diego problem “is particularly concerning” because it was “expected to see one of the largest increases in Medi-Cal enrollment related to the ACA.”
Unwilling to see Medi-Cal patients
Of San Diego area specialists, 54 percent in 2013 and 56 percent in 2015, said they would take a new Medi-Cal patient, the lowest rates in the state.
And of primary care doctors responding, 52 percent and 50 percent said they would accept new Medi-Cal patients, the third lowest rates in the state in those years.
San Diego area physicians are also less likely than those in most other regions of the state to take Medi-Cal patients — new or not.
Those rates were 66 percent in 2013 and 61 percent in 2015 for specialists willing to accept any Medi-Cal patient, the lowest and fourth lowest percentages in the state. Likewise for primary care doctors, 63 percent and 60 percent said they would accept any Medi-Cal patient, the third and second lowest rates in the state.
The problem is a serious one statewide, as well, where 60 percent of all physicians responding in 2015 said they accept new Medi-Cal patients and 64 percent accept any Medi-Cal patients. Those declined from 62 percent and 69 percent in 2013.
It’s about the money
Why don’t more doctors take Medi-Cal? The problem is simple: Medi-Cal pays doctors less than any other payer.
One San Diego area internist said a mid-level office visit for a Medicare patient, which can take 20 minutes, pays $58.76. The same service for a Medi-Cal beneficiary pays just $21.60.
Coffman’s survey found that low reimbursement is the biggest reason, but it isn’t the only reason.
Responding doctors also pointed to Medi-Cal’s “administrative hassles,” payment delays, patients who are more complex or having a full practice. Another reason listed was that Medi-Cal patients “are disruptive.”
Community clinics provide primary care
Dr. Jim Schultz, chief medical officer of Neighborhood Healthcare, said community clinics pick up a lot of the primary care load that would otherwise fall to private practicing physicians. Neighborhood has 11 clinics in San Diego and Riverside counties.
“If there’s something really bad that’s wrong, it can get worse if it takes six months to see a specialist,” Schultz said.
For example, when tests show patients have rectal bleeding, “you really don’t want them waiting six months to have an evaluation.” Tet that sometimes happens. “Sometimes longer,” Schultz said.
If Schultz’ patient in Escondido needs to see a gastroenterologist, he often has to send him or her to Chula Vista, 40 miles away, to see a willing specialist. And many Medi-Cal patients don’t have cars, which means hours on public transportation.
Taking a day off from work, Schultz said, could result in someone not being able “to feed their family that week, or they might lose their job.”
Finding specialists who accept Medi-Cal is a constant struggle. Schultz said that since the ACA expanded Medi-Cal eligibility, many more patients are getting tests to diagnose problems or address long-standing complaints, so they will need referrals.
The situation is less dire for Medi-Cal enrollees seeking a primary care physician because of San Diego’s array of federally-qualified health centers like Neighborhood Healthcare, all of which see about 1 million patients, Schultz estimated. The ACA provides much higher pay for primary care provided at those centers through a complicated formula.
That’s because community clinics provide many services primary care providers do not, such as behavioral health counseling, dental care and retina exams for patients with diabetes, Schultz said.
But community clinics can’t provide all of the primary care required in this region, where primary care doctors are in short supply and many have moved from private practice to large practice groups that don’t take Medi-Cal.
“The fundamental problem is the Medi-Cal reimbursement rate remains incredibly low. We practice in a pretty high cost area and — I can only speak to outpatient reimbursement — when Medi-Cal only reimburses $22 for an office visit that costs a doctor $50 to do, it doesn’t take very many of those visits before you’re losing a lot of money.”
Tobacco tax may provide some relief
That situation could change depending on the outcome of Proposition 56, the tobacco tax increase that voters approved in November. It could bring between $1 billion and $1.4 billion a year to state coffers, a major portion of which is required to pay for Medi-Cal services in a variety of settings. How much physician’s pay will increase as a result, however, remains to be seen and depends in part on whether the $2 increase per pack will prompt more smokers to quit.
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