Jessica Peterson should have been getting ready for her job as an in-home aide and studying for college tests, but instead she was twiddling with her cellphone to occupy herself in the waiting room at Community Regional Medical Center.
As she faced a fifth hour in the emergency department Wednesday, Peterson, 34, said she wouldn’t be at the hospital if her Medi-Cal primary care doctor could have seen her. He didn’t have an available appointment for a month, and she didn’t think she should wait that long. The burning sensation in her left thigh was worrisome — a possible sign of a blood clot — and blood clots run in her family.
“I had no choice but to come here.”
One of the selling points for the Affordable Care Act, which has enrolled millions of Californians in Medi-Cal and Covered California health plans, was that patients with insurance would have primary care doctors to take care of them and less reason to use expensive and overcrowded hospital emergency rooms. However, as the second year of the health law unfolds, emergency departments in the central San Joaquin Valley are busier than last year seeing patients — many of whom have insurance.
Obamacare, as the health law is called, delivered on its promise to get people coverage, but its shortfall has been a dearth of doctors in the community, health officials say.
A doctor shortage has long been a problem in the central San Joaquin Valley and made more so now by an influx of 139,000 Medi-Cal patients. The state-federal program for people with lower incomes now insures more than 850,000 in the Valley — nearly 43% of children and adults.
California and Valley doctors have long been reluctant to accept Medi-Cal — California’s version of Medicaid — because the state has among the lowest reimbursement rates in the country. A likely cut in Medi-Cal pay this year could further erode doctor participation in the program, health officials say.
“All we’ve done is give people a shiny new Medi-Cal card that they’re taking to the emergency department,” said Norma Forbes, executive director of Healthy Communities Access Partners, a Fresno nonprofit agency.
Medi-Cal cases dominate ERs
Emergency department records at Valley hospitals show more Medi-Cal patients are filling seats in emergency department waiting rooms.
Here are three examples:
•Saint Agnes Medical Center
in northeast Fresno saw 34,436 emergency department patients in the five months from July to November 2014 — about 4,000 more than in the same period in 2013. Fifty-two percent of the patients were on Medi-Cal in 2014 as compared to 39% the year before.
•Community Regional Medical Center
had 110,600 emergency department visits in 2014, up from 107,015 in 2013. At Clovis Community Medical Center there were 50,449 visits in 2014, an increase from 46,250 visits in 2013. Medi-Cal patients were 53.4% of the cases at Community Regional in 2014, as compared to 40.2% in 2013. At Clovis, 34.4% were Medi-Cal patients in 2014 as compared to 29.8% in 2013.
•Kaweah Delta Medical Center
in Visalia saw 89,584 patients in 2014 as compared to 86,948 in 2013; Medi-Cal patient volume increased from 44% to 47.7%.
The increase in patients is not all bad, hospital officials said. The Affordable Care Act law has allowed patients not to delay care, because they now can afford it. “That’s a good thing,” said Lindsay Mann, CEO of Kaweah Delta Health Care District. The hospital also benefits when more patients have insurance, he said. Medi-Cal doesn’t cover all the costs of care but it helps. “It is still some level of payment and it has greatly reduced our uncompensated care burden.”
Everyone would be better served, however, if patients with nonemergency health problems were seen in clinics and doctors’ offices, he said.
But there are new concerns that the doctors who now accept Medi-Cal could stop doing so this year. State and federal funds that covered an enhanced Medi-Cal reimbursement rate for health-care providers may not be budgeted. Gov. Jerry Brown’s proposed Medi-Cal budget does not include funds to maintain the boost in pay, and there also appears to be little support in Congress to approve ongoing funding.
Under the enhanced payment, Medi-Cal participating doctors were reimbursed at higher Medicare rates. The California Department of Health Care Services estimates maintaining the enhanced payment would cost $18 billion, of which $700 million would be the state’s responsibility. Medi-Cal already accounts for two-thirds of overall health and human services spending in the state.
No one knows how doctors will react to a payment decrease, but Fresno health providers said it’s likely to push some out of the program and keep new doctors from signing up.
Dr. Ajit Khaira, a Fresno internist, accepts Medi-Cal and intends to continue seeing patients in his office, but said: “I am as frustrated as any other M.D.” Under the enhanced payment, Khaira said he got about $80 for a regular Medi-Cal patient visit. The amount now drops to $22 or $23 a visit, he said. “It’s a big-time loss.”
Medi-Cal patients often tell Dr. Gene Kallsen at Community Regional’s emergency room that they are at the hospital instead of doctors’ offices because they’re unable to find primary care doctors or specialists or get timely appointments. He expects complaints will escalate.
“I’m sure a lot of those patients are going to find their doctors are no longer going to accept their card in the primary care business and the specialty business.” As for new doctors joining the Medi-Cal program, Kallsen said: “Nobody can come up with a business plan where they would enter this market with Medi-Cal rates — not without losing their shirts.”
in the Valley
The Valley has had some success in recruiting Medi-Cal doctors. This year, 396 were added by CalViva Health, the locally governed Medi-Cal managed care plan for Fresno, Kings and Madera counties. The plan also has more nurse practitioners and physician assistants who provide care, said executive director Gregory Hund. And 11 clinics have been added as referral sites that accept the plan’s patients.
Federally qualified health centers and rural health clinics, which receive higher Medi-Cal payments from the federal government, have the capability of adding doctors who participate in the insurance program, but they struggle.
There are not enough primary care doctors who are willing to work in the Valley, said Stephen Schilling, CEO of Clinica Sierra Vista. “I deal with this every single day, constantly,” he said. Clinica operates federally qualified health centers in Bakersfield and Fresno.
There also are not enough medical school students choosing primary care, Schilling said. Nationwide, only 7% of medical students are interested in taking that career route.
Funding to train primary care doctors also could be reduced, Schilling said. Clinica and Healthy Community Access Partners started a health center-based medical residency program last year to train doctors they hope will stay in the Valley. The second class of four students came aboard this past summer, but it could be the last group. It’s uncertain if funds through the Affordable Care Act will be renewed to continue the residency program.
Forbes said her board must make a decision by the end of this month whether to keep the residency program. “It’s very scary for us and for our residents and very scary for our faculty and very scary for everybody,” she said.
Federally qualified health centers and rural clinics are charged with providing primary-care services to the low-income and uninsured. While they continue to hire primary care doctors, they aren’t hiring specialists who are in short supply and who are even less inclined to accept Medi-Cal patients than primary care doctors.
“It’s literally six months sometimes to get an appointment with a specialist and it’s only going to get worse,” said Bill Phelps, chief of programs at Clinica. “It’s going to drive a lot more people to emergency rooms.”
Patients, doctors frustrated
Hospital officials say they have made changes to their triage systems to try to speed waiting times in emergency departments. Most now have increased staffing and redesigned areas to accommodate patients.
They also are trying to educate Medi-Cal patients about alternatives to emergency department care.
Kaweah Delta, for example, has two prompt-care centers, an urgent-care center and another proposed urgent care to take the stress off its emergency department, Mann said. All are busier this year than last. But despite the additions, waiting times in the ER have gone up slightly.
Kallsen of Community Regional said Medi-Cal patients traditionally have used the emergency department about twice as often as people with private insurance and those without insurance. Some abuse the emergency department, he said. “The Medi-Cal population has always seemed a little confused and sometimes a little unmotivated to get to a primary care doctor.”
However, in many instances, Kallsen said: “They legitimately are unable to find a primary care doctor who has good access and accepts Medi-Cal.”
That’s been the experience for Peterson, the Medi-Cal patient who turned to Community Regional for care last week.
She likes her primary care doctor, but he is too busy. She would switch to another doctor who is more accessible, except she hasn’t been able to find one. “I know I don’t have the best insurance, but they should see patients.”
An emergency room visit is not something she wants to repeat.
She said she sat for 10 hours before being seen by an ER doctor. An ultrasound ruled out a blood clot as the cause of the pain in her thigh, but the cause was not determined.
Peterson said she was told to see her primary care doctor for follow-up care. Hopefully, she can stand the pain — and stay out of the emergency room — until then, because “I don’t want to go through this again.”