10:00 PM PST on Wednesday, November 19, 2008
More California doctors this year enrolled in the state program that covers health care for the poor, but some providers who have signed up aren't seeing those patients because they say the state doesn't pay enough to do so.
That forces thousands of patients to vie for appointments with doctors who will see them or to rely on hospital emergency rooms, which are required by federal law to treat them.
A little more than 110,000 doctors statewide this budget year agreed to accept the state's estimated 6.5 million patients who rely on Medi-Cal, according to the California Department of Health Care Services, which operates the program. During the 2006 budget year, almost 104,000 doctors statewide were enrolled in Medi-Cal.
But Inland participation in the program dropped from a little more than 5,600 doctors to nearly 4,825 during the same time period, according to state statistics. An estimated 700,000 Medi-Cal patients live in the Inland area.
Stan Rosenstein, chief deputy director of the state Health Care Services Department, said it's unclear how many doctors enrolled in the program are declining to see Medi-Cal patients and what gaps in medical care are being created as a result.
Doctors don't have to notify the agency when they choose to decline patients.
"We're not able to drill down to where a particular doctor has decided to limit his participation," Rosenstein said. "It's a problem for every payer."
Dr. Dev GnanaDev, president of the California Medical Association, said he thinks the total number of doctors enrolled in the Medi-Cal program is deceiving.
"The Department of Health Care Services thinks all these doctors are still out there and they are not," GnanaDev said. "The specialty services rates are so horribly low that doctors can't even make their overhead."
Medi-Cal is California's Medicaid program, a public health insurance program that provides health care services for low-income people, including families with children, the elderly, some disabled people, foster children and pregnant women. It also covers low-income people with specific diseases such as tuberculosis, breast cancer, HIV and AIDS.
The state and federal governments equally fund the program. Medi-Cal's rates, last increased more than a half-dozen years ago, are among the lowest in the nation.
In 2005-06 budget year, California spent $2,701 per Medicaid beneficiary, according to the Kaiser Family Foundation, a nonprofit, private organization that researches national health care issues. The national average was $4,662 per Medicaid beneficiary.
Earlier this year, California lawmakers approved 10 percent cuts totaling $568 million to Medi-Cal payments to help balance the state budget and reduce its multi-billion-dollar deficit. But a federal judge stopped the cuts, saying they were harming patients and health care providers.
Still, providers sign up or stay in Medi-Cal because it would take nearly a year to re-enroll if they dropped out, GnanaDev said.
"If you are in the program you don't have to see any Medi-Cal patients," he said. "A lot of people have actually stopped seeing those patients."
Meanwhile, Renee Eblen recently had to push for an appointment with the only neurologist in San Bernardino County who will accept Medi-Cal patients.
About three weeks ago, doctors found a cyst on the brain of Eblen's 6-year-old daughter, Paris. From the time of diagnosis, it'll be about six weeks before Paris sees the neurologist, her mother said.
Eblen said she originally had been told she could have to wait five months for an appointment. She got one sooner because of an opening created by a cancellation, she said.
"I've been fighting tooth and nail to get referrals," Eblen said.
In September, Molina Healthcare of California, a privately owned Medi-Cal health maintenance organization in Colton, instructed its doctors to stop referring Medi-Cal patients to Loma Linda University Medical Center for obstetrics and routine pediatric care.
Molina has about 90,000 Inland members. It's unclear how many patients have been affected by the decision.
"(Loma Linda University Medical Center) has made a business decision to limit their financial exposure for services provided to Medi-Cal patients," according to a letter by Katherine Bradley, regional manager of Molina Healthcare's provider service/contracting, and Dr. Richard Sanchez, its chief medical officer.
In a written statement released Friday, Loma Linda Medical Center's administration described Molina's letter to its providers as an oversimplification of the facts surrounding recent contract restructuring.
"LLUHC continues to provide extensive services to the Medi-Cal population throughout the region and has not changed its fundamental commitment to the Medi-Cal program," according to the statement released by medical center spokeswoman Joy Jameson. "Medi-Cal patients have been, and will continue to be, a significant portion of the patients served by LLUHC's physicians."
Molina spokeswoman Kathleen O'Guin said she couldn't comment on Loma Linda Medical Center's decision.
Lisa Rubino, president of Molina Healthcare of California, said in a written statement that the organization's Medi-Cal patients still have more than 500 health care providers to pick from, including a variety of specialists.
In April, Dr. Anoop Maheshwari, a Corona pulmonologist, stopped accepting new Medi-Cal patients because of low payments. Medi-Cal reimbursement for a follow-up office visit is roughly $16, a small portion of the total $75 office cost, he said.
"It's practically a free visit," said Maheshwari, who doesn't bother to pursue reimbursement when Medi-Cal doesn't pay.
He said he considered declining his established Medi-Cal patients, too.
"I decided against it because I knew it was going to be an extreme hardship on them," he said. "The trend is going more toward not taking Medi-Cal."
Since at least 2001, state officials have known that Medi-Cal's payment rates for doctors were lower than those paid by Medicare, the federal health care program for the elderly and handicapped, and other providers.
That year, the state's Legislative Analyst's Office found that Medi-Cal payment rates were about 60 percent of those paid by Medicare. The Legislative Analyst's Office, which provides nonpartisan fiscal and policy analysis for the state Legislature, recommended that lawmakers raise Medi-Cal rates to 80 percent of those paid by Medicare.
However, a 2007 report prepared for the state Health Care Services Department shows that Medi-Cal rates still are about 61 percent of those paid by Medicare.
Rosenstein said Gov. Arnold Schwarzenegger understands the need to keep doctors enrolled in Medi-Cal, which gets nearly $15 billion in state funds. But payment increases require revenue sources, which the state doesn't have, he said.
"It takes a lot of money in an environment where the state has major financial problems," Rosenstein said. "We're trying to manage as best we can."
Dr. Jeffrey Luther, president of the California Academy of Family Physicians, said it is not unusual for Medi-Cal patients to travel from one end of a county to another to get an appointment with one of the few doctors who will see them, he said.
Meanwhile, Inland health care experts say the area already doesn't have enough doctors to care for its estimated 4 million residents. The problem strains everyone when doctors refuse to treat Medi-Cal patients because of poor reimbursement, they say.
The state's low Medi-Cal rate also discourages new doctors from coming here to practice, said Dr. Guillermo Valenzuela, chairman of Arrowhead Regional Medical Center's women's health department. Three doctors who he trained have accepted jobs in Texas, Tennessee and Washington, he said.
"The reimbursement rates are not increasing with the costs of doing business," said Valenzuela, who also is president of the San Bernardino County Medical Society.
The Inland area has about 114 doctors for every 100,000 residents, according to research conducted for UC Riverside and its medical school proposal. The state average is 209 doctors per 100,000 residents.
Health care experts say more loan-forgiveness programs for doctors who agree to practice in the state's underserved areas or a medical school at UC Riverside could lure more doctors to the Inland area. But doctors won't stay long if Medi-Cal rates don't improve.
"In the long term, it makes a lot of sense to have a medical school here," Valenzuela said. "Medical students tend to remain where they do their residency training. However, the differential in salaries across the country is getting so high. Reimbursements here have to improve."
Reach Lora Hines at 951-368-9444 or lhines@PE.com