Healthcare Crisis: Not Enough Specialists For The Poor
LA Times, December 15, 2012
With months-long waits for Medi-Cal patients to see specialists, some turn to emergency rooms — exactly what healthcare reform is banking on avoiding.
By Anna Gorman, Los Angeles Times
The blurry vision began early last year. Roy Lawrence ignored it as long as he could. But after falling off a ladder at his construction job, he knew he had to see a doctor.
He went to a community health clinic in South Los Angeles, where doctors determined he had diabetes and cataracts. The clinic could manage his illness but referred him early this year to the county health system for eye surgery.
Nearly a year later, Lawrence, a Jamaican immigrant without insurance, still is waiting for the operation. His vision has deteriorated so much he is considered legally blind.
PHOTOS: Waiting in vain to be seen
“I want to see again,” he said. “I’ve been waiting a long time.”
Lawrence, 49, and patients like him are posing a critical challenge for the planned overhaul of the nation’s healthcare system. Federal officials are investing billions in community health centers like the To Help Everyone (T.H.E.) Clinic, where Lawrence’s problem was diagnosed, with the hope that they can keep more patients out of high-cost emergency rooms.
But a dearth of specialists available to low-income patients presents one of the bigger hurdles facing the country as it tries to bring spiraling healthcare costs under control. Doctors say meeting new government mandates to keep patients healthy and out of hospitals — a linchpin in reducing medical spending — will be virtually impossible without the ability to make timely patient appointments with specialists.
By the end of the decade, the nation will be short more than 46,000 surgeons and specialists, a nearly tenfold increase from 2010, according to the Assn. of American Medical Colleges. Healthcare reform is expected to worsen the problem as more patients — many with complex and deferred health needs — become insured and seek specialized treatment.
Many of the newly insured will receive Medi-Cal, the government plan for the needy as administered through the state of California. Clinics already struggle to get private specialists to see Medicaid patients because of the low payments to doctors. Last week, an appellate court decision that authorized the state to move forward with 10% cuts in Medi-Cal reimbursement, which could make finding doctors for those patients even more difficult.
“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” said Mark Dressner, a Long Beach clinic doctor and president-elect of the California Academy of Family Physicians. “We’re really disappointed and concerned what it’s going to do for patient access.”
The healthcare overhaul includes initiatives aimed at reducing shortages of general medicine professionals but does little to increase the availability of specialists.
In Los Angeles County, the sheer volume of poor or uninsured patients needing specialist services has long overwhelmed the public health system, creating costly inefficiencies and appointment delays that can stretch as long as a year and half.
Patients’ conditions often must be dire for them to see a neurologist, cardiologist or other specialist quickly. Community clinics try to bypass the backed-up formal government referral system by pleading, cajoling and negotiating to get less critically ill patients like Lawrence moved up on waiting lists.
“Where needs are absolutely critical, we are able to work out special arrangements,” said Rise Phillips, chief executive of T.H.E. Clinic. “That is not the norm. That is, rather, the exception.”
At times, clinic staff members are forced to work against one of their key missions by sending patients to emergency rooms to increase the odds of their seeing a specialist more quickly.
The challenge can be seen in Belinda De Leon’s cubicle in a small, windowless back corner of T.H.E. Clinic. A referral specialist, De Leon spends her days trying to speed up appointments for the center’s clients — and fielding calls from patients wanting to know how much longer they have to wait. At any given time, she’s juggling more than 1,000 pending referrals.
One involves uninsured housekeeper Juana Barrera. Barrera, 45, has been waiting since April 2011 to see a gastroenterologist and get a colonoscopy. She has had bleeding off and on and recently started having pain in her stomach.
On a recent visit, she told De Leon she is scared to wait any longer. But she can’t afford to pay for the test out of pocket. “I’m hoping it’s not anything like cancer,” she said.
De Leon promised to update Barrera’s referral paperwork to indicate she is experiencing pain. “Hopefully that will help,” she said.
Waits for specialist appointments vary dramatically, depending on the type of specialist needed. Patients willing and able to travel across L.A. County to specialty clinics may be able to see a doctor within a month or two. Others who lack transportation and must go to a nearby facility can wait up to a year for a dermatologist or neurologist and up to 18 months for a cardiologist or ophthalmologist.
The county is trying to make the system more efficient, reduce wait times and ensure that those who don’t need more advanced care don’t overburden the system, said Mitch Katz, head of the L.A. County Department of Health Services. County officials risk losing newly insured patients, along with government funding, if they can’t find ways to reduce the bottleneck.
One focus is using technology to improve communication and better screen patients. A pilot program, for example, is allowing primary care doctors at community and public clinics to quickly transmit patients’ medical information via computer to a public health specialist for a consultation.
The electronic consults are streamlining referrals and helping clinic doctors make better treatment choices, said Louise McCarthy, executive director of the Community Clinic Assn. of Los Angeles County.
During an August visit to T.H.E. Clinic, Lawrence saw nurse practitioner Sandeep Lehil for the first time. He told her he was controlling his diabetes with medication and a modified diet. But his vision wasn’t getting any better.
“My eyes are really bad,” he told Lehil. “I can barely see.”
Lawrence’s medical record showed that he wouldn’t be seeing an ophthalmologist for many months.
“That’s a long time to live with blurry vision,” Lehil said.
“By that time, I’ll be blind maybe,” Lawrence responded.
Lawrence, who has a soft voice, an accent and a lanky frame, arrived in the U.S. nearly 20 years ago to pick apples, and overstayed his visa. He can’t work or drive, and he relies on others to cook meals to avoid burning himself. His immigration status prevents him from getting health insurance or unemployment benefits. He lives with a friend, spending most days listening to a television he can barely see. When the phone rings, he lifts it almost to his nose to see who is calling.
In mid-October, Lawrence was back at the clinic and saw a different, fill-in doctor who knew nothing about his situation, nor when his surgery would be scheduled. “You haven’t received any notice?” asked physician David Hwang. “No, not yet,” Lawrence answered, adding that he checks his mailbox every day.
De Leon, the referral clerk, later gave Lawrence unwelcome news: The wait to see an ophthalmologist at the county’s Harbor-UCLA Medical Center was still about a year. She said she was trying to get him an appointment elsewhere sooner.
Weeks later, Lawrence took matters into his own hands. With the help of a friend, he took three buses to reach the emergency room at Los Angeles County/USC Medical Center northeast of downtown. He waited several hours but finally saw an emergency room physician, who managed to get him an appointment the next day with an eye doctor.
“You have to do what you have to do,” Lawrence said.
At the medical center’s specialty clinic, ophthalmologist Simon Bababeygy told Lawrence his cataracts probably were caused by his diabetes, high blood pressure and high cholesterol.
He described the surgery he would perform, on one eye at a time. And he spoke the words Lawrence had been waiting for: He should be seeing much more clearly by the end of the year.
Preparing for the surgery, doctors got an abnormal result on a heart test. Now, Lawrence has to wait to see a county cardiologist before going back to Bababeygy to schedule the eye operation. He has no idea how long that could take.
“Every time, it’s something else,” he said. “My eyes are getting worse. And now it’s my heart.”
Times staff writer Anna Gorman reported aspects of this story while participating in the California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School of Journalism.
Copyright © 2012, Los Angeles Times
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LA Times, December 13, 2012
Court Ruling Could Cut California Spending On Medi-Cal
A 9th Circuit appeals panel decides California can reduce its Medi-Cal reimbursements to doctors, pharmacies and others. Providers say the doctor shortage will worsen.
By Maura Dolan and Chris Megerian, Los Angeles Times
SAN FRANCISCO — In a potential windfall for the state, a federal appeals court decided unanimously Thursday that California may cut reimbursements to doctors, pharmacies and others who serve the poor under Medi-Cal.
A three-judge panel of the 9th Circuit U.S. Court of Appeals overturned injunctions blocking the state from implementing a 2011 law that slashed Medi-Cal reimbursements by 10%. Medi-Cal, a version of Medicaid, serves low-income Californians.
The ruling could make it harder to find doctors for as many as 2 million new patients who could become eligible for Medi-Cal under President Obama’s healthcare law — a possible 25% expansion of the program. California already provides one of the lowest rates of reimbursement in the nation for medical services to the poor, and there is a shortage of doctors to serve those patients.
Lynn S. Carman, an attorney for a group of pharmacies, said the decision would be costly for providers, worsen the doctor shortage and would be appealed.
“If this decision stands it will not only destroy the Medicaid program in California, but it will destroy the Obamacare program for millions of Americans who are now being shoved into the Medicaid program under the Affordable Care Act,” Carman said.
“They will not be able to obtain quality healthcare or access to services because providers cannot provide services at less than what it costs to furnish them,” Carman said.
The ruling could make it considerably easier for the state to close its budget gap.
The state is facing a $1.9-billion deficit next year, although Proposition 30’s temporary tax hike and an improving economy are projected to shift the state back into surpluses in the near future.
Medical providers said Thursday that the cutback should be lifted now that the state’s fiscal outlook has improved. The ruling can be applied retroactively to June 1, 2011.
“Now that the state has money, it would be like Scrooge for Gov. Brown not to pass a bill to eliminate at least the retroactivity part of it,” Carman said.
For the governor, Medi-Cal cuts could serve one policy aim at the expense of another.
Balancing the budget has been Brown’s first priority since taking office, and cutting healthcare — the state’s second-biggest cost after education — has been key to his fiscal goal.
But at the same time, he has wanted California to be out front in healthcare reform, and lead the country in efforts to put the federal law into place.
A spokesman for Gov. Brown released a statement Thursday that implied that Brown was inclined to put his budget priorities first, and was not likely to rescind the cuts.
“Today’s decision allows California to continue providing quality care for people on Medi-Cal while saving the state millions of dollars in unnecessary costs,” the spokesman wrote.
In a ruling written by Judge Stephen S. Trott, appointed by President Reagan, the panel said the lower court injunctions were unwarranted because the federal government had approved the cuts.
“Neither the State nor the federal government ‘promised, explicitly or implicitly,’ that provider reimbursement rates would never change,” Trott wrote.
California has estimated that the 10% cut to medical providers and pharmacies would save the state $50 million a month.
Medi-Cal typically covers families and disabled Californians. The federal law will extend its coverage to single, childless adults beginning in 2014.
The California Medical Assn., which joined dentists, pharmacists, medical suppliers and medical response companies in trying to block the cutbacks, urged Brown to repeal them.
Dr. Paul R. Phinney, president of the doctors’ association, said the cuts shrink the number of providers who could afford to serve both existing Medi-Cal patients and the new ones who could become eligible for coverage in 2014.
“We need to ensure that health insurance isn’t just an empty promise for these patients,” Phinney said.
According to the California HealthCare Foundation, Medi-Cal patients already have difficulty finding doctors.
A foundation study published in July 2010 said 25% of physicians provided care to 80% of Medi-Cal patients.
Although 90% of physicians told the foundation they were accepting new patients, only 57% said they were taking on new Medi-Cal patients.
Dr. Ted Mazer, a San Diego ear, nose and throat surgeon, said he had to stop taking fee-for-service Medi-Cal patients several years ago because the reimbursements didn’t cover his costs and Medi-Cal patients were inundating his practice.
“So few doctors will see Medi-Cal patients that I was seeing them from the Mexican border to Riverside County to Orange County,” said Mazer, an officer of the California Medical Assn. “The reimbursement costs are so poor they don’t even cover costs, let alone pay for the administrative hassle. I can only see so many until I go under.”
Chris Perrone, deputy director of the foundation, said Thursday’s ruling will make it harder to block rate cuts in the future.
“The hurdles for people who want to block these rate cuts are little higher,” said Perrone.
Dolan reported from San Francisco and Megerian from Sacramento.
Times staff writer Anna Gorman contributed to this report.
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