March 4, 2014:
Fifty-year-old Long-Beach resident Sovothy Pak is on Medi-Cal, the state’s low-income health insurance program, and that turned out to be a complication when tumors from her cervical cancer began bleeding.
Her doctors said she needed radiation to stop the bleeding. But she couldn’t get in to see a specialist.
She weakened and was in growing pain. “We had to take her to the emergency room (for a transfusion) because her red blood cell counts were so low,” said Pak’s son-in-law Mike Wilson.
Finally, after multiple calls to Pak’s Medi-Cal medical group and lobbying by an outside nonprofit group, Maternal and Child Health Access, Pak got the radiation therapy she urgently needed a month later.
That was in August. Since then hundreds of thousands of newly eligible Californians have signed up for Medi-Cal through the Affordable Care Act, raising new questions about the access and availability of specialist care in the system.
The Department of Health Care Services, which administers Medi-Cal, reports that 8.5 million people are currently enrolled. Under the Affordable Care Act (ACA) expansion, another 1 million to 2 million people will be eligible to enroll this year.
The department maintains that there are enough physicians to serve the expanded population, but says it does not know how many specialists will be willing to take on new Medi-Cal patients.
According to a 2010 report done for the California HealthCare Foundation, two-thirds of all specialists in the state see Medi-Cal patients. But their doors are not wide open. One-third of specialists in urban areas limit their Medi-Cal patient load to 20 percent of their practice, and one-third restrict it further to between 1 and 5 percent.
The report found that only 65 specialists were available per 100,000 Medi-Cal beneficiaries. That compares to the American Medical Association’s estimates that 85 to 105 are needed to adequately serve a population.
Experts say that the number of specialists taking Medi-Cal patients has likely declined since that report was published, propelled by low reimbursement rates.
Dr. Andrew Bindman, director of the University of California Medicaid Research Institute and one of the report’s authors, said there has been slow erosion in the number of specialists participating in Medi-Cal over time. “But California started with pretty low participation (in Medi-Cal) in general attributed to California having among the lowest rates of reimbursement for physicians in any state,” he said.
Gov. Jerry Brown’s 2014-2015 budget eliminated a 10 percent retroactive cut in Medi-Cal reimbursements, but retains a 10 percent cut in future payments to physicians as part of an effort to keep the state budget balanced.
Dr. Ruth Haskins, an obstetric gynecologist in Folsom, said she expects to deliver 20 babies a month, and has traditionally limited the number of expectant mothers on Medi-Cal to five a month because Medi-Cal’s reimbursement was just 25 percent of commercial health plan rates on average.
“Once we hit five, we’ve had to say, ‘so sorry, we can’t do it,’” she said, unless the mother is a former patient or has been referred by another doctor.
Now she expects to see even fewer Medi-Cal patients. Not only is she facing the 10 percent Medi-Cal cut, but reimbursement for patients under Covered California will also be much lower than under commercial health plans, she said.
“I can only take a mix of 5 patients total (per month) from Medi-Cal and Covered California,” she said.
According to the Medi-Cal Managed Care Dashboard briefing released by the California HealthCare Foundation in December, thousands of Medi-Cal patients are struggling to get access to specialists.
Martin Cantu is one of them. The 52-year-old Fresno man was referred to an endocrinologist last July because of bone-numbing fatigue from a thyroid condition that makes getting the morning newspaper from the curb so tiring that he has to rest after the exertion.
His appointment, however, is set for May — a full 10 months after he was first referred by his doctor at the Clinica Sierra Vista. “It’s frustrating is what it is,” said Cantu, who misses having the energy to go out to the store to pick up groceries.
“Our staff is dealing with this all the time,” said Steve Schilling, the CEO of Clinica Sierra Vista. “Sometimes it’s like hitting your head against the wall.”
Schilling’s clinics in the Central Valley serve 155,000 patients annually. Among the most difficult specialist appointments to get are with orthopedists, psychiatrists and gastroenterologists, he said.
Part of the reason, he thinks, is that specialists tend to choose to practice in desirable locales. “You can’t pry folks out of the Bay Area to enjoy 108 degrees in Bakersfield in July.”
But even in more desirable areas, getting specialist appointments for people on Medi-Cal isn’t easy. Finding specialists in oncology, neurology and orthopedics is a huge challenge, according to Cathy Woodcock, the director of practice operations of the Petaluma Health Center in Sonoma County.
Mike Wilson said his family was grateful for the care his mother-in-law received once she got to see her specialist. But he does wonder if the delay contributed to her declining health as the cancer has spread.
Wilson was also surprised that in an area as populous as Los Angeles there wouldn’t be a specialist closer to home.
“Her oncologist was out in Sherman Oaks, 50 miles from her house (in Long Beach) through L.A. traffic,” Wilson said. “So it was a two-hour drive one way. It’s insane how far it was.”
Patients who have urgent health problems have been denied authorization for care, are experiencing long delays in their Medi-Cal or have been unable to resolve problems with their Medi-Cal health plan, can call the Department of Managed Care’s Help Center at 1-888-426-2219.