The doctor isn’t in: Medi-Cal patients struggle to find primary care

Oct. 06--The kitchen table in Kathy Poe-Barham's Rocklin mobile home is littered with paperwork -- a mixture of junk mail, which her disabled son Michael Poe loves to sort through each morning, and stacks of letters from the state about her impending shift into Medi-Cal Managed Care.

Poe-Barham is elbow-deep in a legal battle with the Department of Health Care Services to keep her 28-year-old son on the Medi-Cal fee-for-service plan that has covered the dozens of surgeries, treatments and medications he has needed since being diagnosed with a brain tumor at age 3. If he moves to managed care -- a subset of Medi-Cal that relies on insurance plans to provide reimbursement to doctors -- she fears he won't have access to any of it.

The 68-year-old full-time caregiver has been seeking options for Poe in the event that he loses his current coverage, but she said the physicians in her area were all closed to new managed care patients. The health department's attorney, she said, told her to bring Poe, who is mentally impaired, partially blind and immune-compromised, to the UC Davis Medical Center emergency room for help.

As California continues enrolling people under the Affordable Care Act and shifting the majority to Medi-Cal managed plans, the growing share of doctors refusing to accept low-income patients due to inadequate reimbursement rates from the state has thousands wondering where they can go for care.

"All the poor people in California, they're trying to force into this Medi-Cal box ... and in this box you have people like my son, who are just going to fall through the cracks," Poe-Barham said. "The insurance companies don't pay (doctors) enough, and the state won't pay them enough, so they drop it. And we can't force them to take it. So what are we supposed to do out here?"

The state budget for low-income health programs has been running low since the 2007-09 recession, said Anthony Wright, executive director of the consumer advocacy group Health Access. Gov. Jerry Brown has not restored the 10 percent cut made to Medi-Cal reimbursement in 2011, despite pushes from Wright's group and others. With one in three Californians on Medi-Cal and enrollment efforts still in full swing, experts are taking a hard look at whether the program is fulfilling its promise of providing care for the newly insured.

In 2014, California had the third-lowest Medicaid reimbursement rate in the nation, falling behind only New Jersey and Rhode Island, according to a report from Washington, D.C.-based think tank The Urban Institute.

"The ACA wasn't designed to address (the physician shortage) problem -- it was trying to get more of the uninsured covered," Wright said. "There are millions of people for whom Medi-Cal is a lifeline. At the same time, we aren't meeting our goals and standards for providing that full coordination of care that was promised."

Much of the local outrage about the provider shortage has been targeted at UC Davis Medical Center, which in January 2015 ended a Medi-Cal Managed Care contract with insurance plan Health Net, forcing about 3,700 patients to find new providers.

Since then, about 40 community groups and 160 UC Davis medical students have formed the Health Equity Action Team. They held a news conference in August to urge the hospital to negotiate a new managed care contract.

"They don't think (a Medi-Cal managed care program) is profitable and they aren't looking for one," said Amy Williams, deputy director for Legal Services of Northern California and an organizer for the action team. "They won't sit at the table. ... That's what we see as the problem here -- a public hospital that doesn't want to serve the community."

Ann Boynton, director of payer strategies and value-based contract management for the hospital, said ending the Health Net contract was not a decision the administration took lightly, but felt was necessary from a financial standpoint. The low Medi-Cal reimbursement rates have been an "enormous financial challenge" for the last few years, she said.

"(Hospitals) are closing their doors ... because the total reimbursement they are receiving is inadequate," she said. "Rates by the state through the Medi-Cal program are quite frankly insufficient to cover the cost of care provided. It's not just a Davis problem, it's a systemic problem."

A recent California Health Care Foundation study found that only 55 percent of primary care physicians are accepting new Medi-Cal patients -- a dip from the 57 percent in 2013 who said they would take the plan.

Seventy-six percent of hospital-based and emergency room physicians said they were accepting new Medi-Cal patients, while only 57 percent of doctors in surgical specialties and 37 percent of psychiatrists said the same.

When a major public entity such as UC Davis pulls its physicians, the picture becomes even more disconcerting, said Janet Coffman, associate professor of health policy at the University of California, San Francisco, who led the study.

"There are community health centers, there are other sources of primary care in Sacramento, but losing a large provider of primary care does raise concern," she said. "The people that were receiving care there, will they be able to find it somewhere else? Is there enough capacity? There's reason to ask questions."

Fern Baum, 63, noticed the problem firsthand when she moved to Fair Oaks from the Los Angeles area earlier this year and had to re-enroll in Medi-Cal. She was given a hefty pamphlet of providers who were supposed to take her insurance, but were unavailable when she gave them her family's plan information, she said.

She recently began working as an office assistant, and enrolling in her company's health plan has been a huge relief, she said. But her adult son is still on Medi-Cal in Los Angeles and may have trouble establishing primary care, she said.

"The doctors don't want to take Medi-Cal patients," Baum said. "We couldn't find a doctor. ... I have a master's degree, and it's this complicated. I can't imagine for someone who doesn't have a computer or any support who's trying to figure this out."

About 78 percent of physicians surveyed by the California Health Care Foundation said they limit the number of Medi-Cal patients in their practices because of the low payments, while 72 percent cited delays in Medi-Cal payment and other administrative hassles.

Dr. Carla Kakutani, a family physician at a Sutter Health-affiliated practice in Winters, said she keeps her Medi-Cal patients to about 15 to 20 percent of her total patient load and takes private insurance to make up for the financial loss. For a basic office visit, Medi-Cal pays about $20 while private insurance would pay about $60, she said.

"Basically, they're asking physicians to lose money in their business for seeing these people," she said. "I work in a small town, and I want to be part of the health care solution for the entire community, not just one piece of community. ... If I could take the financial concerns out of the equation, I would want to see whoever needs to see me. But the current payment structure is making it difficult."

The Department of Health Care Services doesn't see "any problems with network adequacy" in the Medi-Cal program but is still taking "measures to resolve the issues, which could include revisiting provider payments," spokesman Anthony Cava said in an email.

"The size and diversity of California, unfortunately, can mean shortages of certain specialists across all systems of care in some geographies," Cava said.

A flurry of state legislation has addressed the Medi-Cal shortfall, from bills requiring more insurance plan accountability to budget proposals that would revive expired physician training and recruitment programs, especially in rural areas where the doctor shortage is especially dire.

On the November ballot, Proposition 56 would charge a $2-per-pack tobacco tax for health funding that proponents hope will funnel millions toward Medi-Cal provider reimbursements.

Coffman said hospitals and community clinics could also increase their capacity with telemedicine and other creative solutions.

"Those are places that have always welcomed Medi-Cal beneficiaries," Coffman said

For Michael Poe and other Medi-Cal patients dealing with complex conditions, clinics and emergency room visits just won't cut it, Poe-Barham said.

"It has been such a long road," she said as her son squirmed restlessly in a kitchen chair. "It's becoming a huge debacle, and it's not working ... the whole thing just doesn't make sense for him."

Sammy Caiola: 916-321-1636, @SammyCaiola

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