Health & Medicine

Why more Medi-Cal patients ended up at the ER after UC Davis cut their primary care

UC Davis second-year medical student Alisha Othieno, left, examines patient Maricella Moran at the Imani Clinic in Sacramento on Saturday. Imani Clinic is a UC Davis medical student-run clinic that helps folks in the south Sacramento area get some basic services. Medi-Cal patients hoping to get primary care services sometimes face long wait times at hospitals or centers, so this student-run clinic helps individuals who fall between the cracks.
UC Davis second-year medical student Alisha Othieno, left, examines patient Maricella Moran at the Imani Clinic in Sacramento on Saturday. Imani Clinic is a UC Davis medical student-run clinic that helps folks in the south Sacramento area get some basic services. Medi-Cal patients hoping to get primary care services sometimes face long wait times at hospitals or centers, so this student-run clinic helps individuals who fall between the cracks.

Ian Kim sees the dire effects every day of UC Davis Medical Center’s decision to stop providing basic care for some of Sacramento County’s most vulnerable patients.

This past year, a boy came into the hospital’s emergency room with an infection so serious that, if not well managed, could have led to the loss of a limb or even death, said Kim, who is a resident physician at the medical center.

After several days of treatment, Kim and his team were able to get the infection under control. But that was only half the battle. The infection and its location – which Kim could not specify due to patient privacy laws – required close and lengthy follow-up care after discharge. But because the boy is on Medi-Cal, he couldn’t receive any of those services at UC Davis.

“We had to bend ourselves into a pretzel to make sure he got to a right hospital,” said Kim, who added that the boy currently receives follow-up care from a UC Davis Medical Center physician who works at another health system.

“It took a lot more time than it should’ve had to, and it puts him and his family in a vulnerable position because the solution isn’t a long-term one,” Kim said.

More than 440,000 low-income people depend on Medi-Cal countywide, but with few exceptions, none of them can seek primary care services such as checkups and consultations at UC Davis without paying out of pocket. UC Davis stopped accepting Medi-Cal coverage more than two years ago, saying the federally funded health program for low-income people didn’t adequately reimburse the hospital for its services.

Before UC Davis took over the facility in 1973, the center had served as the county hospital, and many still view it as a public good, providing equitable health care, including preventive care, at a convenient location with a familiar and experienced staff. UC Davis’ last Medi-Cal contract ended in January 2015 with insurance provider Health Net for its roughly 123,000 patients in Sacramento County, following years of the hospital dropping Medi-Cal contracts with other insurers.

That has left thousands of low-income patients looking for primary care at other health systems that, while still allowed to accept Medi-Cal patients, have become flooded with others coming from UC Davis.

“(They have) a hard time getting prescriptions,” Kim said, “a hard time getting follow-ups and check-ins, (and) navigating paperwork and new systems with other clinics when what they really need is just good access to a good doctor and team.”

Contract negotiations are confidential and can’t be disclosed, according to UC Davis spokesman Charles Casey. But Ann Boynton, UC Davis Health’s director of payer strategies and value-based contract management, said the reimbursements the UC Davis system receives from the federal government are inadequate to cover all costs of care.

“As any business entity, you have to look at what’s the balance on the financial side,” Boynton said.

She added that the center remains “deeply committed” to the community, as evidenced by its other health services such as the UC Davis Children’s Hospital, and to say otherwise is “a bit of an oversimplification.” UC Davis Health also continued to provide continuity of care for a year to patients approved and authorized by Health Net, Casey said.

The shortfall has widened since the Affordable Care Act in 2014 expanded the number of people eligible for Medi-Cal, said Amy Williams, deputy director for Legal Services of Northern California. In Sacramento County, the number of people with Medi-Cal coverage has risen by 9.6 percent since the expansion, and statewide, about 3.7 million people have since joined Medi-Cal.

“More people have eligibility but where the heck are they going to go and get those services?” Williams said. “The ACA only works if people start using primary care and preventative care.”

Today, some Medi-Cal patients may still be referred to UC Davis for specialty care by their physician, Casey said. Most receive primary care services at federally qualified health centers such as Planned Parenthood and WellSpace Health, but the clinics don’t always have the specialty services UC Davis can provide during primary care visits.

Overall, the void created by UC Davis Health has impacted a range of health care providers, particularly in south Sacramento where the medical center is located. Some patients have to wait “months and months” before getting an appointment, Williams said.

Other Medi-Cal patients get so sick that they end up at UC Davis anyway, in the emergency room, where Medi-Cal patients can still receive treatment but where care is far costlier.

“It would make a lot more sense to just get primary care,” Kim said.

Because of emergency services and specialist referrals, Medi-Cal patients continue to make up about 36 percent of people discharged from the hospital, Casey said, and are the hospital’s “single largest payer in terms of volume.”

“We serve a vital function providing higher levels of care beyond that of a primary care provider, and this is a critical aspect of caring for managed Medi-Cal patients,” Casey said in an email.

Many Medi-Cal patients, such as Leslie Love, 58, had been seeing UC Davis primary care doctors for decades, sometimes for complex conditions and illnesses. UC Davis is where the south Sacramento resident got a knee replacement in 2014, and it was where she intended to receive the necessary follow-up physical therapy.

But when she arrived at the hospital for her appointment in 2015, they turned her away because her insurance didn’t cover the service. She was only able to keep her physical therapy sessions for 30 days through a judge’s order.

“They wouldn’t let me even see the surgeon so I could talk to him,” Love said. “Everybody knew me there, knew me well, nurses, doctors. I was just stunned. I couldn’t believe it.”

After going from “clinic to clinic to clinic” to find a female primary care doctor, she was finally assigned one at Sacramento Community Clinic. But Love said she had to wait several months for the doctor to be authorized and approved by Medi-Cal for physical therapy sessions.

Today, Love walks with a limp in her left leg because of how long she had to forgo treatment, and is no longer looking to receive physical therapy.

“What good is it going to do?” Love said. “I needed it when I got surgery and the doctor said, ‘Make sure you get therapy.’”

Health professionals such as Kim have responded to the need by helping patients navigate a patchwork health system that overburdens local health centers and sends people to hospitals too far for some patients to travel to on their own – hospitals that sometimes still turn people away because they’re too crowded.

In addition, UC Davis medical students – many of whom support reinstating primary care services for Medi-Cal enrollees – have offered free clinics that have become a kind of safety net, Williams said. They provide basic screenings and diagnoses, but are open only once a week, and can’t connect patients back to UC Davis for specialized treatments, she said.

Some hospitals, including UC Davis Health, have responded by freelancing doctors out to local health centers, Williams said. Dignity Health even runs vans that make sure patients can get to their appointments.

UC Davis Health officials have restarted talks with the Health Equity Action Team, or HEAT, a local health coalition working to re-establish primary care access for many of Sacramento’s poorest communities.

In addition, UC Davis Health recently negotiated a new Medi-Cal contract with insurance plan UnitedHealthcare, which is set to go live Oct. 1, according to Casey. The plan, however, is expected to cover fewer than 500 people, Williams said.

“It’s like putting Band-Aids on something that is profusely bleeding,” said Kim Williams, director for Sacramento Building Healthy Communities, a foundation that helped form HEAT.

UC Davis Health is “actively working” to secure more Medi-Cal managed care plans, Amy Williams said. In the meantime, HEAT is hoping to negotiate short-term solutions such as creating a mobile clinic or transportation services to other facilities in the county, she said.

“We are very committed as a public hospital. We’re not shirking away from our responsibilities,” Boynton said. “We’re a Sacramento institution.”

Still, Kim said the last 2 1/2 years have been “heartbreaking” for many of the doctors, nurses and medical students working at UC Davis. Like him, they were drawn to UC Davis because of its legacy improving health care access to disenfranchised people. In fact, some UC Davis medical students depend on Medi-Cal themselves, which means they can’t get primary care services at the facility where they study and work.

“This hospital has a history of being a county hospital and has a reputation for being one of the places people can go to get health care,” Kim said. “No one who cares about health care for the poor can accept that UC Davis doesn’t have access for poor people here.”

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