California created one of the most innovative Medicaid programs in the country. Then it ran into the same wall every state runs into — the doctors.
A patient of ours lived in a California county with serious health issues: coronary artery disease, emphysema, heart failure, diabetes, high blood pressure and high cholesterol. He took 12 medications.
Because of his “high acuity,” ER and hospital admissions history, his Medi-Cal health plan granted him access to an unbelievable benefit: CalAIM (Advancing and Innovating Medi-Cal), a massive initiative by the California Department of Health Care Services to integrate medical care with social services for Medi-Cal members with very complex medical, behavioral and social needs.
Under the auspices of this program, he was assigned a lead care manager from an enhanced care management provider. The job was to help him with the “social determinants of health,” and manage all the non-clinical barriers that keep people from getting the care they need. Simply put, enhanced care management gave him access to a team that would make his appointments with his primary-care provider and specialists, ensure he had enough medications to comply with his plan of care, oversee an appropriate dietary regime, and organize consistent checkups to make sure he stayed on track and got healthy.
Once the care management team saw the patient’s full medical picture, they felt it was necessary to make sure he could see a primary-care physician. While sitting by his side, the care manager called the doctor’s office. They were told that no visits were available for this Medi-Cal patient for eight weeks. But he wasn’t “generally well,” he was “generally very sick.” Specialist doctors gave similar responses. The care manager was stuck between a rock and a hard place, trying to get this patient urgent medical care appropriate to his condition.
This happens daily and the typical default is to go to the very expensive and non-efficient ER. California has solved a huge part of the problem by creating CalAIM enhanced management programs, deploying providers to help patients in desperate need of assistance. But we haven’t solved the physician and hospital components that are critically important part of a patient’s care.
Many doctors don’t see or don’t want to see Medi-Cal patients. It’s all about pay. In fact, the latest federal government adjustment reduced physician fees by 2.8 percent, exacerbating the problem. California voters passed Proposition 35 in November 2024, to increase pay to doctors treating Medi-Cal patients, but it hasn’t been implemented yet.
The payment pressure doesn’t just affect who gets seen, it also shapes how they’re seen.
Some medical practices try to create goals for how many patients a physician should see in a day. I’ve seen numbers as high as 35 per shift. One practice tried to limit the number of medical complaints per appointment to one. Our chronically ill patient would suffer in the hands of this type of care and return to us for more help. This is not a physician problem. It is a design problem, and we need to fix it.
Remarkably, California has established a goal to directly address this problem: directing 15 percent of all Medi-Cal spending to primary care by 2034. Today, that number sits at just 7 percent, meaning the state is asking its Med-Cal patients with the most medically-complex conditions to be served by a primary-care system that receives less than half the investment the state itself has deemed necessary, according to the California Office of Health Care Affordability report in 2024.
The state’s CalAIM program has worked miracles for many patients. But a quarter of those who qualify for the benefit are not getting it. The latest enrollment stats show about 178,000 members are actively enrolled in the program, but about 700,000 are estimated to qualify (approximately 5 percent of the state’s 14 million Medi-Cal members).
California showed it could be foresightful, bold and patient-minded when it created CalAIM. Now it needs to be bold again, implementing Proposition 35 without further delay and building a physician payment structure that actually matches the complexity of the people it is meant to serve. Care management can work miracles to open the door to better health. But someone must be on the other side of it.
Gray Miller is president of Titanium Health, a Garden Grove-based Medi-Cal enhanced care provider that serves patients in 37 counties in California.
