Barriers to Care Persist Despite Expansion of Medi-Cal

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The Affordable Care Act, with its promise of health care for most Americans, represents a welcome step forward for physicians who have cared for the uninsured.

Michael Core, a primary care doctor at The USC Eisner Clinic, treats some of the city’s poorest people in a spare no-frills office just south of downtown Los Angeles. Core says it’s great that his previously uninsured patients have access to a range of specialists that they never did before—at least on paper.

Many of them are part of the ACA’s huge expansion of the state’s Medi-Cal program. State officials say the increase in recipients—3 million new enrollees in 2014— hasn’t affected the quality of service they receive, but both patients and physicians report potentially dangerous long waits for specialty care.

Many of the newly insured are baffled by insurance and have trouble navigating the health care system. Core now spends much of his time deciphering his patients’ paperwork and helping them cut through insurance company red tape.

Many of the clinic’s patients come from the communities just south of LA’s central core, where incomes are low and many people live in crowded conditions. The area suffers a severe shortage of primary care doctors and dentists and is considered medically underserved by the federal Department of Health and Human Services.

On a rainy Thursday afternoon as Core prepares for an afternoon clinic, he learns that one woman he’d planned to see that day just passed away after battling kidney cancer.

“She should have seen an oncologist right away,” Core said.

Instead, she saw the specialist months after her diagnosis, delaying chemotherapy that should have begun within weeks.

Her managed care plan, LA Care, had denied her referrals to some of the specialty care she needed. Core’s patient was also repeatedly denied medication for potentially fatal blood clots because the insurer said a pulmonologist should have written the prescription, not Core, the primary care physician.

“Authorizations would come super late, so she’d go a week or two without blood thinner,” Core said. “You’re trying to coordinate care, and then you’re getting denied.”

“A story like that is absolutely unacceptable,” said John Wallace, LA Care’s interim CEO. “There are a lot of safeguards to make sure things don’t deteriorate. The health plan can be their advocate. What you find in the Medi-Cal population is that people are disenfranchised. They don’t know that regulations are in place to help them.”

It’s impossible to know if Core’s patient would have survived or lived longer had she gotten the care she needed on time.

“But it doesn’t help the perception,” Core said. “Someone has a terminal disease, and you don’t seem to be getting help, but barriers. The system is designed to provide barriers.”

Some 70 percent of Medi-Cal beneficiaries are enrolled in managed care plans. In exchange for a per person payment from the state, the plans are required to offer medically necessary care to all of their members. Medi-Cal beneficiaries who are not in managed care are in what’s called fee for service Medi-Cal in which the state reimburses physicians directly.

Two managed care plans serve Los Angeles County. LA Care is a non-profit overseen by the county Board of Supervisors and contracts with commercial plans to cover  nearly two thirds of beneficiaries. Health Net, a commercial plan, insures the rest.

But Core and other physicians report that some of their sickest patients can’t get timely specialty appointments, or have trouble obtaining the medications they’re prescribed.

The obstacles are particularly irksome to Core, who chose family medicine to offer quality health care to poor people.

Growing up poor in East Los Angeles, he was especially sensitive to the divide between rich and poor.

“I’d see the disparities on TV, and wonder, why isn’t my life like that?” he said. Then his family moved to the suburbs, and he saw first-hand that middle class people enjoyed better opportunities than those in his old neighborhood. The class divide loomed even larger when he was accepted to Yale University as an undergrad.

“It didn’t feel right,” he said, “that I could advance socially and economically and my friends couldn’t.”

He figured he’d do his part to close the gap as a family doctor in an area where physicians and especially Latino physicians are in short supply.

On this day, his first patient is 65-year-old Wassell Grissom, who wears a plaid fisherman’s cap and comes in with a sheaf of papers and an oxygen tank attached to a walker. Grissom has lung disease, high blood pressure, high cholesterol, and hepatitis C, from which he thinks he’s recovered with new medication, and perhaps a cold.

Core listens to his lungs, which sound pretty good, except for a crackle, which may be the cold he’s developing.

But most of the visit is taken up with untangling Grissom’s insurance troubles.

Grissom, whose managed care plan is Health Net, has come to the clinic because he ran out of medications and can’t get his prescriptions filled. He’s also having trouble getting all of the oxygen tanks he needs.

“The pharmacy only gave me a few pills because the doctor wasn’t registered through the insurance plan. Another problem, I’m on so many medications. The insurance company only allows four to six medications at a time each month. I have to get all my meds. At least I get my choice [of which medications to purchase],” Grissom said.

Core began practicing medicine just a few years before President Obama’s first term, when the Affordable Care Act was conceived, and although he backs the reforms, he says they don’t go far enough.

Many doctors won’t accept Medi-Cal patients at all, or do so selectively because Medi-Cal payments to California physicians are among the lowest in the country, while the costs of doing business are among the highest.

What’s more, physicians are in short supply altogether, and in rural areas or poor neighborhoods like those in South LA they’re even scarcer.

Just 32 physicians practice in zip codes 90011 and 90037, which include the communities just south of the Eisner clinic, according to Medical Board of California data. By contrast, 834 doctors are listed in zip codes 90049 and 90024, which include the wealthy communities of Pacific Palisades and Brentwood.

Still, Medi-Cal managed care plans like Health Net and LA Care report that their physician networks are sufficient to serve their patient loads in every region of the county.

So-called provider network reports for both plans for the third quarter of 2014 show compliance with state standards, which require that a single physician’s patient load not exceed 2,000 people.

But those reports provide little solace to patients whose assigned doctors can’t give them appointments for more than a month, or to those who might be seeking care from physicians who are out of business altogether or who no longer accept Medi-Cal.

A check of LA Care’s primary care doctors in the 90011 and 90037 zip codes shows that of 16 physicians’ offices contacted, two are no longer in business. One number was disconnected and the other rang up a skilled nursing facility whose medical staff didn’t include the doctor that LA Care listed.

Three medical offices couldn’t offer adult appointments for three weeks or more, even though state standards and the plans’ contract with the Department of Health Care Services require that non-emergency primary care appointments be available within ten working days.

Of 21 specialty care physicians’ offices contacted in the area, five in the LA Care directory were no longer in business, or were no longer located in the area. Two didn’t accept Medi-Cal patients at all.

All but one of those who said they did accept Medi-Cal, however, could book an appointment within 15 working days, meeting the state’s standard of care.

“First and foremost, the information should be up to date,” Wallace said, adding that it’s not easy to update because thousands of providers are changing addresses and affiliations. “We put a lot of resources into keeping data accurate.” Wallace also noted that a member who wanted to change doctors would go to the plan’s member services department, and wouldn’t necessarily need the published provider directory.

Medi-Cal is heading for a crisis, with a huge increase in enrollment in recent years, Leah Newkirk said in an email. Newkirk is the vice president of the San Francisco-based California Academy of Family Physicians. The organization has collected 70 responses from family doctors to a survey on Medi-Cal access. Most of them noted difficulties in getting specialty care for their patients, especially neurologists, endocrinologists, psychiatrists, rheumatologists, pain management specialists, orthopedists, and referrals for imaging or drugs

“Most respondents describe patients being shuttled in and out of the system as primary care physicians scramble to find a specialist who will accept a Medi-Cal patient,” wrote CAFP’s Abhinaya Narayanan in a summary of the results.

State regulators do not believe the crisis that Newkirk cites exists. Sarah Brooks, Chief of the Managed Care Quality and Monitoring Division at the Department of Health Care Services said the huge increase in Medi-Cal beneficiaries has not affected the quality of their care.

But LA Care’s Wallace argued that the influx of members has indeed required some adjustment in his network. Medi-Cal members used to be primarily moms and kids, but now adults with complicated conditions are entering the system.

“We have lots of work going forward to refine our delivery model now that we have the new membership,” Wallace said.

Still, Medi-Cal beneficiaries’ problems with access to health care have caught the ear of legislators, regulators and advocates.

The state legislature’s Joint Legislative Audit Committee has ordered the state auditor to investigate the adequacy of Medi-Cal managed care networks, as well as the state’s oversight of the plans, and the governor has signed legislation to tighten managed care regulation, including for Medi-Cal beneficiaries.

In his office near the end of his day, Core says he’d like to get the insurance companies out of the business of medicine altogether. “We just need single payer,” he said.

Still, Core argued that even if all the obstacles to care were removed, there still wouldn’t be enough physicians to serve all of California’s patients, especially those who depend on public insurance programs like Medi-Cal.

Second in a series. 

Also: When clinics aren’t a last resort and sick patients denied care.

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