INLAND: Medi-Cal contractor struggles with more patients, less pay
This article originally appeared in The Riverside Press-Enterprise and the San Bernardino County Sun.
At midmorning, the two parking lots are full and cars line the curb. Inside, the waiting room of the LaSalle Pediatric Medical Clinic in San Bernardino is packed.
Most of the young patients are on Medi-Cal, the health care program for the poor, which now covers half of the state’s children.
In an exam room, party planner Artelli White sits with her two children, Tessa Murphy, 5, and Ardynn Murphy, 7.
The care, White said, is “pretty good.” But she expects that she will wait at least two hours and that when she finally sees a doctor or physician assistant, the visit will be “kind of rushed: ‘Here’s your prescription. Have a nice day.’ ”
Her experience is increasingly common as Medi-Cal copes with an explosion in enrollment ignited by expanded eligibility under the Affordable Care Act. The Inland Empire Health Plan, the dominant Medi-Cal contractor in San Bernardino and Riverside counties, enrolled 350,000 new members last year, a 56 percent increase, among the fastest growth rates of any Medi-Cal plan in the state.
Now IEHP must serve those new members while simultaneously coping with state and federal cuts in doctor pay – all this in an area that has struggled for years to attract doctors.
The decision by the U.S. Supreme Court on Thursday affirming federal subsidies for health insurance exchanges nationwide has no effect on IEHP’s situation, other than to add further legal stability to the Affordable Care Act.
IEHP – created as a nonprofit agency 19 years ago by the two county governments to better organize healthcare services for the poor – is innovating to meet the challenge.
The billion-dollar health plan is shifting tens of millions of dollars to pay physicians above the rates authorized by the state and federal governments. It’s also offering bonuses to lure physicians to the Inland Empire: $100,000 for primary care doctors and $150,000 for specialists.
But these moves may not have come quickly enough.
Key quality measures slipped in 2013 just as membership was beginning to surge. In a survey last year, IEHP members gave doctors poor ratings even while they praised the health plan’s customer service.
In an interview at his Rancho Cucamonga office, IEHP chief executive Bradley Gilbert said he is worried that quality could suffer as a result of the patient influx.
“With this growth in membership, I’ve got physicians saying to me, ‘I’ve got so many new members that are coming into me for care that it’s making it hard for me to focus on preventive services.’ ”
In mid 2013 IEHP had one primary care physician for every 811 members. Today the ratio is one to 1,186.
If anything, those numbers understate the doctor shortage in much of IEHP’s vast turf. There are 2,263 members for each primary care physician in the High Desert area around Victorville, 2,528 in the Hemet region, 3,690 in Barstow.
The doctor shortages would probably be worse if IEHP had followed the state government’s lead and reduced Medi-Cal reimbursements by 10 percent late last year. Instead Gilbert scrambled to keep paying doctors at the old rate – a $20 million-a-year commitment.
Even that is not enough because Medi-Cal, California’s version of the federal-state Medicaid program, is a bad deal for doctors. A 2012 survey by the Kaiser Commission on Medicaid and the Uninsured found that California tied for the 49th lowest payment rate among the 50 states and the District of Columbia. At that time – before the 2014 cut – California paid physicians 51 percent of the Medicare rate to treat Medi-Cal patients.
The gap has widened in the past year as Congress increased Medicare payments while the Legislature cut Medi-Cal. Consider a routine 15-minute office visit: A doctor can bill Medicare between $52.52 and $83.18 depending on whether the visit occurs in a hospital or the doctor’s office, but if the patient is on Medi-Cal, the doctor can bill just $24.
As an inducement to treat millions of new Medicaid patients, the Affordable Care Act offered doctors a special deal: For two years they’d get paid at the much higher Medicare rates.
Those higher rates expired at the end of 2014 – a cutoff that Gilbert called “a bait-and-switch.”
The IEHP board decided to fund Medicare-level payments to primary care physicians through the end of this month or “whenever the money runs out,” Gilbert said. The cost: $45 to $50 million. Because of built-in payment lags, doctors will continue to be paid full rates for as long as six months.
Gilbert isn’t worried about covering the 10 percent Medi-Cal cut by the state.
“I can afford that,” Gilbert said. “What I’m worried about is, doctors for two years got Medicare level payments, which is big money. … You know, these doctors joined IEHP, and part of the reason they joined was the increased rate of payment. What will they do when it’s gone?”
Earlier this month, the California Legislature passed and then turned back a pay raise for doctors who treat Medi-Cal patients. In its place they agreed with Gov. Jerry Brown to begin paying for Medi-Cal coverage for children who are in the country illegally, a plan that initially will cost $40 million a year.
There are no plans in Congress to restore Medicare-level funding for Medicaid.
While Gilbert tries to hold onto the doctors he already has, he’s recruiting new ones.
“The Inland Empire,” Gilbert said, “starts out disadvantaged.”
It has about half the national average of primary care physicians – general practitioners, family practice doctors, internists, pediatricians – for its population.
G. Richard Olds, dean of the new medical school at the University of California Riverside puts the region’s overall physician deficit at 3,000 and says it could reach 5,000 within a decade.
Money for once is not the cause.
A survey by Doximity, a professional network for physicians, shows that Riverside County physicians in a range of specialties earn the same average pay as their peers in Los Angeles County and better than their counterparts in Orange and San Diego counties. San Bernardino County physicians do better across the board.
The region has a doctor deficit, Olds said, because “California did not keep up with its growth.”
Nearly a half-century elapsed between the opening of the UC medical schools at Irvine and San Diego in the mid-1960s and the opening of the UC Riverside medical school in 2013. During that half-century, the combined population of Riverside and San Bernardino counties swelled from less than 1 million to more than 4 million.
Most physicians, Olds said, choose to practice where they grew up or where they performed their residencies. The fast-growing Inland Empire has few native physicians and, until the opening of UCR medical school, the only local suppliers of resident doctors were the medical school in Loma Linda and the osteopathic medical school at Western University in Pomona.
The first doctors from UCR will begin practicing on their own in 2020, though 200 residents and 60 faculty members already are treating the public, Olds said. But it will be several years until the young medical school makes a big impact.
Gilbert can’t wait that long.
Last September the IEHP board agreed to offer the hefty bonuses – officially a “network enhancement fund” – to help physician groups and hospitals recruit new doctors.
To date IEHP has offered money for 74 primary care physicians and 53 specialists. So far 16 doctors have committed.
The physician groups can do what they want with the money.
“It could be an income subsidy for the doctor,” Gilbert said. “It could be a hiring bonus for the doctor. It could be equipment for the office.
“What I care is that they get a new doctor. That’s all I care about, a new doctor in the Inland Empire.”
The need is enormous.
IEHP must contend with one million patients, a third of them newly insured, many dependent until recently on emergency rooms.
Gilbert calls it “Managed Care 101”: “Take care of them on the outpatient side. Get them in as best health status as you can. And that may mean more medication. It may mean more doctor visits. But then what you do is you try to reduce emergency department and inpatient (hospital) visits.”
Dr. Albert Arteaga heads LaSalle Medical Associates, one of the largest physician groups in the IEHP network. A minister’s son, Arteaga frequently likens his four clinics to churches.
“Improved access or more open access is probably going to induce a period of chaos until it gets under control,” Arteaga said. “I mean, if you’re this great big, bad sinner and you go to church one time, that’s not going to get you very far. You have to keep going.”
On a recent day, physician assistant Allison Atkinson treated three teenagers, all 5-foot-3, all weighing over 200 lbs.
“Pediatric patients are now super-sized,” Atkinson said.
The reasons are varied. Typically both parents work. Fast food is readily available. Home-cooked meals are not. And there is a cultural component: Mexican immigrants or the children of immigrants can be suspicious of tap water.
“Many of these people are drinking three or four sodas a day,” Atkinson said. “These are my patients.”
“We’re already seeing Type 2 diabetes in their early teens, and this will be a serious health issue in their future,” she said. “We see that all day, every day.”
Getting such patients early attention is critical to reducing costs later. Dr. Octavio Ruiz, who practices at walk-in clinics in Perris and Montclair, said Medi-Cal is improving the chances of his poor patients getting preventive care.
“We send them to colonoscopies and mammograms” that they could not afford when they were paying cash, he said.
Getting to the next level is more problematic.
“There’s not enough specialists,” said Dr. Mario Carcamo, a pediatrician in Riverside. In an emergency, patients can get in quickly. But otherwise, “it might take four months to get an appointment,” he said, especially for neurologists and orthopedists.