Advocates question children’s access to care

A year after California added nearly a million children to the Medi-Cal program, advocates say the state is not doing enough to ensure that all of those kids have access to doctors and other health care providers.

Most of the children came from the old Healthy Families insurance program, a state and federal program that provided subsidized insurance for low-income children whose families could not afford insurance but earned too much to qualify for Medi-Cal.

The program was popular, but changes brought about by the federal Affordable Care Act prompted to merge Healthy Families into Medi-Cal. At the same time, about 200,000 additional children were made eligible for Medi-Cal.

The switch was supposed to save the state about $40 million, in part because doctors in Medi-Cal are paid less than they were in the Healthy Families program.

At the time the decision was made, children’s advocates were concerned that the transition would overwhelm Medi-Cal, which already didn’t have enough doctors. The worry was that patients wouldn’t be able to find a doctor accepting new patients.

Now those same advocates are warning that nobody really knows how access to care was affected by the change.

The California Children’s Health Coverage Coalition recommends that the state Department of Health Care Services do a “secret shopper” type survey to see how many Medi-Cal doctors are accepting new patients and how long it takes to get in for an appointment.

“A watch dog can’t watch much if the reporting processes aren’t there,” said Judy Darnell, vice president of public policy at United Ways California, one of the members of the coalition. “We’re asking for a comprehensive audit that provide information of children’s experiences in Medi-Cal.”

Alison Buist, director of healthy policy for the Children’s Defense Fund, another coalition partner, said there isn’t enough data to prove that patient access is a problem. “If you look at the numbers, it’s hard to see it’s not a problem.”

Norman Williams, deputy director of public affairs at the state Department of Health Care Services, said the state communicates with all the health plans on a regular basis to ensure that patients have access to doctors. “We are always monitoring access,” he said. When the state is alerted about any problems, it works quickly to correct them, he said.

A state evaluation of the transition released in April 2014 indicates that that most kids were able to keep the same primary care provider. While the report said it was too soon to know for sure if the transition was a success, it said there was evidence that “goals set out by the transition are headed in the right direction.”

Alice Mayall of Livermore said her son lost access to autism therapy benefits and had a harder time getting mental health services when they made the switch from Healthy Families to Medi-Cal. But she was glad that they were able to remain with Kaiser. “It appears to make zero difference within the Kaiser system if you have Kaiser through Medi-Cal, Healthy Families, employer or whatever,” she said. “I’ve certainly had no difficulties getting providers within Kaiser.”

The state took steps to ensure that the transition went as seamlessly as possible. For instance, there are now Medi-Cal managed care plans in every county. When the decision to phase out Healthy Families was made, some counties didn’t have managed care plans that contracted with Medi-Cal. Eighty percent of members are on managed care plans now, Williams said. They have a primary care provider who coordinates all their care and are not forced to look in the phone book for every specialist they might need as they would under a fee-for-service system. There is also a Medi-Cal Ombudsmen’s Office that patients can contact for help with problems (the phone number is 888-452-8609).

But some reports indicate there is reason for concern. Ninez Ponce, a researcher at the University of California at Los Angeles found in an ongoing study funded by the California Healthcare Foundation that children on public health insurance were five times more likely than kids on private plans to have visited the emergency department for asthma. “There might be difficulties in seeing a regular provider,” Ponce said. Ponce added, however, that on other access measures, children on public coverage did as well as children on private coverage. Her full report will be published this spring.

Another area of concern is that as of Jan. 1, reimbursement rates for Medi-Cal doctors dropped 60 percent. This is for two reasons- a temporary bump in reimbursement rates provided by the Affordable Care Act expired and a 10 percent reduction in state reimbursement rates went into effect. This rate reduction might discourage doctors from taking Medi-Cal patients.

“It’s hard to see how rates can drop and drop and drop and you continue to have the same access to care,” said Buist, of the Children’s Defense Fund.

In Riverside and San Bernardino counties, one health plan is using financial incentives to get more Medi-Cal doctors. The Inland Empire Health Plan is giving up to $100,000 per physician to medical practices that hire doctors that will accept Medi-Cal. Bradley Gilbert, M.D., the plan’s CEO, said the money can help pay the first year of the physician’s salary when that physician is just beginning to generate income. The doctors have to agree to stay three years. If they leave within the first year, the practice will have to repay the money. Gilbert said he had to do something because the Inland Empire has the worst ratio of primary care doctors to its population in California.

The incentive program, which began last fall is a resounding success, Gilbert said and so far has brought in 104 new physician positions – 58 primary care doctors and 46 specialists. “Suddenly we’ve created access for thousands of patients,” he said.

If the experience of Modesto parent Cathleen Spencer is typical, the state may have a problem.

“There’s a list that has 10,000 doctors but no one takes new patients, said Spencer, the mother of a 3-year-old.

Spencer said she was able to find only one clinic in town that accepted new Medi-Cal patients. She would have preferred to stay with the pediatrician she had through Healthy Families, but that doctor doesn’t accept Medi-Cal.

But it’s hard to know for you sure if patient access to Medi-Cal is an issue without the data. Kristen Golden Testa, director of the California health program for The Children’s Partnership, hopes the state will survey providers to see how they handled the influx of patients to Medi-Cal from Healthy Families.

“We’re not anywhere where we know if there is an impact with a reduced private network with this population,” she said.

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