When Dr. Jerold Kaplan made a home visit last year to a man with a foot wound, he billed Medi-Cal — the state’s health care program for the poor and disabled — what he thought was a modest $90.
His payment: $8.96. The Berkeley wound surgeon received a bit more for his home visit to a quadriplegic last year: $13.44. Medi-Cal told him it cut both payments in half because of late paperwork. But even at the full rate, he would have received no more than $27 for a house call — barely enough to cover gas.
As California gears up for a major expansion of Medi-Cal under national health reform, such compensation is leading to a critical concern:
- Will enough physicians be willing to see the influx of new patients?
Many doctors now refuse to accept Medi-Cal patients or sharply limit the number they see because of what they describe as extremely low reimbursement rates. As a result, patients report difficulty getting timely care, a problem the expansion could worsen.
“Medi-Cal has gotten so ridiculous in its reimbursement there are a lot of doctors that aren’t interested in working for it,” Kaplan said. Now covering 7.7 million Californians, Medi-Cal is the state’s version of the federal Medicaid program.
It is expected to grow by 900,000 children with the state’s recent elimination of the Healthy Families program, which provided low-cost insurance for children and teens. The state will enroll an additional 1.5 million or more adults when national health reforms take effect in 2014. All told, Medi-Cal could balloon by 30 percent, financed largely by an additional $9 billion a year in federal money beginning in 2014.
Many consumer advocates strongly support the expansion and argue that it will greatly benefit the state by giving preventive care to those who are uninsured, helping them avoid more serious — and more costly — illnesses. “It’s going to be a huge boon to not just the newly covered Californians, but to our health care system as a whole,” said Anthony Wright, executive director of Health Access California. But Wright agreed work needs to be done to make sure the program is ready.
- California has one of the lowest Medicaid reimbursement rates in the nation, ranking 47th of 50 states. And it could drop further.
In a budget move, state lawmakers last year approved a 10 percent pay cut for Medi-Cal providers. But the cut is on hold pending a ruling on a lawsuit doctors filed.
- While patients generally laud the program, 23 percent of adults report difficulty in finding a primary care doctor who will accept Medi-Cal, and 34 percent have had trouble finding a specialist, according to a 2011 survey by the California HealthCare Foundation.”If they can get established with a physician at all, they have to wait much longer for an appointment and as a result, they are going to the emergency room for routine care and that clogs up the ER,” said Dr. William Lewis, a Los Gatos ear, nose and throat doctor and past president of the Santa Clara County Medical Association.
“That is clearly going to get worse if you’re adding people without adding doctors.”
Medi-Cal pays Lewis $15 to $20 for an office visit, compared with the $50 he gets from Medicare and $60 to $70 from a private insurer.
The Medi-Cal rates are so low, Lewis said, he doesn’t bother billing for it because it’s not worth the hassle. He just eats the cost. Lewis typically declines to see new Medi-Cal patients unless it is a follow-up visit with someone he treated in a hospital emergency room. “You cannot run a practice seeing Medi-Cal patients,” he said. “You can’t pay your employees and pay for your overhead and keep your doors open.”
Statistics on the number of physicians who accept Medi-Cal are hard to come by. The state has nearly 80,000 doctors enrolled as Medi-Cal providers, a number that has held fairly steady over the past five years, said Norman Williams, spokesman for the state Department of Health Care Services.
But critics counter that many of those physicians see only a patient or two, or have closed their practice to new Medi-Cal patients. Under the national health reform law, Medi-Cal payments for primary care doctors will rise to Medicare levels in 2013 and 2014, Williams noted. That will mean a significant pay boost in California and should help ensure there will be enough doctors to see patients, he said.
But the boost will not apply to specialists, and many primary care doctors may be reluctant to accept new patients fearing the rates will drop back in 2015, said Dr. Ted Mazer, an officer with the California Medical Association and a San Diego-based ear, nose and throat surgeon.
The state will monitor Medi-Cal patients’ access to doctors, and if problems develop, “we’ll take immediate action,” Williams said. Some fear that the doctors, clinics and hospitals that see Medi-Cal patients now will be inundated once the expansion occurs.
When San Mateo mom Macrina Mota’s daughter injured her foot playing soccer last year, the two spent 13 hours in an emergency room to treat a sprained foot. “They’re just overbooked; they’re overloaded,” Mota said.
Other Medi-Cal recipients encounter different barriers. New mother De Jornae Thomas, of Oakland, said having Medi-Cal has helped ensure that her 2-month-old son, Josiah, has the medical attention he needs. But because Medi-Cal requires her to pay a cost-sharing fee, she avoids checkups for herself. “I haven’t been to the doctor in awhile for myself, outside of my pregnancy,” she said.
East Oakland pediatrician Brian Blaisch is on the front lines of the debate, with nearly 90 percent of his 1,500 patients on Medi-Cal. Despite his commitment to such families, Blaisch now only occasionally accepts new Medi-Cal patients and moonlights at two hospitals to make ends meet, which makes for 60-hour workweeks. He said he has maxed out loans on his home to keep his practice afloat.
Still, Blaisch strongly supports the Medi-Cal expansion but said the state may need to expand community clinics and offer financial incentives to encourage more doctors to see Medi-Cal patients. “For me, it’s just a mission,” he said. “This is what I grew up thinking I was going to do.”
*Modified from a Mercurynews.com article