Health & Medicine

Why Medi-Cal enrollees gain coverage but not broad access to doctors

Medi-Cal enrollee Michael Gonzalez worked for months in 2015 to get to the Sutter specialists who ultimately treated his thyroid cancer, so he felt undermined this summer when Sutter Health announced that its primary-care doctors would no longer be serving 10,000 adult patients in Sacramento and Placer counties.

Dr. Ken Ashley, the director of primary care for Sutter Medical Group, said in August that Sutter was working with the health insurance company Anthem to shift those patients to primary-care doctors at community health clinics such as Sacramento’s WellSpace, Elica and the Sacramento Native American Health Center. Known as federally qualified health centers, these clinics provide primary and preventive care to patients regardless of their ability to pay or their health insurance status.

Ashley said the switch would be better for patients because many clinics provide dental, vision, behavioral health and medical services all under one roof, but the change came as a blow to Gonzalez and other Sutter Medi-Cal enrollees who contacted The Bee.

“I’m thinking about just moving out of Sacramento County,” Gonzalez said. “I’m going to see if I can find a place with a better health care system than what Sacramento has to offer.”

Even though the Affordable Care Act has expanded the ranks of people covered by Medi-Cal, Gonzalez and other Medi-Cal enrollees say they face challenges establishing medical homes with the major physician groups readily available to California leaders and to many rank-and-file workers. That’s because many large physician groups no longer contract with health plans serving adult Medi-Cal patients, saying that government reimbursements are too low to cover the cost of treating patients.

In many cases, Medi-Cal pays doctors just 6 percent more than they were paid in 1985 to treat adult Medi-Cal patients, said health-care consultant and former Medi-Cal administrator Stan Rosenstein. There was a 16 percent increase in rates in 2000, he said, but amid an economic downturn in 2009, state officials rolled back that increase by 10 percent.

Physicians expected broad-based rate increases after the November passage of Proposition 56, which generated $1.3 billion in Medi-Cal funding with a $2-a-pack cigarette tax. But only $466 million of that went toward boosting rates for dentists and physicians. Even though matching federal funds will double that, it’s too little too late for many physicians.

For the typical office visit, Medi-Cal pays doctors only about a third of what their peers at federally qualified health centers receive, $150 on average, Rosenstein said. If the health centers’ fees exceed what insurers will pay, Rosenstein said, their administrators can bill the state for the residual amount. So, he said, the state is forced by federal law to pay more for office visits at federally qualified health centers than it would have paid physicians in private hospital groups.

“The state has to take cost data from the federally qualified health centers and create a specific rate for those providers,” Rosenstein said. “Then they’re required to give a built-in cost-of-living increase every year ... and so these rates have gone up extensively at the same time the Medi-Cal physician office rates have not.”

That is true, said Carmela Castellano-Garcia, president and CEO of the California Primary Care Association, but studies have shown that government agencies pay less in the long run for health care coverage from federally qualified health centers. In a look at data from 2014, the National Association of Community Health Centers reported health centers had average daily costs per patient of $2.09, compared with $3.06 for all physician settings. Overall, a 2016 study found, spending by health centers was 24 percent lower than other providers.

“Because we keep more people out of the hospital, it’s actually more cost-effective to serve them at a community health center,” Castellano-Garcia said. “It’s not necessarily true that the state is paying more for these patients because, in the end, it costs less to serve them at a community health center, even if the per-visit rate is higher.”

The difference in cost doesn’t mean that health centers cut corners on patient care, Castellano-Garcia added. A lengthy list of federally reported metrics back up that contention: Pregnant women, for instance, have a lower incidence of low-birth-weight babies at health centers than in the general population. Health-center patients have higher rates of control of diabetes and blood pressure than the national average, and they are more likely to have standard cancer screenings than people in the general population.

“They (health centers) are providing a much more comprehensive range of services,” Castellano-Garcia said. “Patients are going to get access to the preventive care, the dental care, the eye care, nutrition, prenatal care – you name it. It’s a broad range of comprehensive services that is not what you can find in a private physician’s office. You’re actually getting something different when you go to a community health center, and that justifies in the minds of the federal government why they are paid a differentiated rate.”

Gonzalez, however, is not impressed by the metrics. He recalled an office visit he made to an Elica Health center in East Sacramento, where a doctor told him he’d be exposed to more radiation from an MRI than he would from an X-ray. Gonzalez told the doctor that an MRI used magnetic resonance, not radiation, and argued with her over it until Gonzalez called up an FDA site showing that MRI’s didn’t use ionizing radiation.

Elica Health CEO Ken McGuire said he was not familiar with Gonzalez’s case and could not discuss it even if he was, due to privacy restrictions, but he said he hopes that all doctors at Elica adhere to the standards of care they learned in medical school.

Gonzalez said he wants ready access to a medical home with doctors he trusts and he found that at Sutter. The medical provider is essentially abandoning patients, he said, by shifting them to federally qualified health centers but not ensuring access to the specialists that patients had as members of its networks. He spent months calling and showing up at Sutter doctors’ offices before he found a physician who had room for him in his practice.

“It was a battle to get into the Sutter Health system when I had Medi-Cal, but eventually I found a doctor that was sympathetic enough to take me,” Gonzalez said. “I had a friend who knew somebody at Sutter Roseville, and they told me that Jay Owens was the best thyroid surgeon for oncology in Roseville. So, I set out to get myself established at Sutter.”

For Ashley, the movement of patients to federally qualified health centers is akin to when employers change insurers and workers have to find new primary-care doctors and specialists. Gonzalez, however, noted that those employees typically still can choose from doctors in major provider networks and have easy access to specialists. In the Sacramento region, adult Medi-Cal enrollees currently can find health plans offering primary-care homes at Kaiser and, on Oct. 1, will be able to do so at UC Davis. Dignity Health doctors receive payment directly from Medi-Cal if they are open for new Medi-Cal patients.

Gonzalez said he received exceptional access as a Sutter member: “I’ve had surgery twice in the past two years, and it was not hard at all to get a referral to a specific doctor I asked for. I needed an oncologist in Roseville, and they shepherded me to the exact doctor I needed.”

Castellano-Garcia, McGuire and other health center administrators acknowledged that waits for specialists can be lengthy at federally qualified health centers, depending on the type of service. The Bee contacted the Health Resources and Services Administration and the National Association of Community Health Centers but could find no data on these wait times.

As for access to Sutter specialists, Anthem spokeswoman Olga Gallardo said that will depend on whether Sutter doctors contract with the provider groups serving the federally qualified health centers. Local health centers contract with physicians from River City, EHS, Hill Physicians, Nivano or Imperial medical groups, she said.

In some cases, provider networks have worked out access to specialists prior to the patient transfers, Castellano-Garcia said, and that type of partnership alleviates both patient anxiety and systemic delays. She said health centers have had to be innovative to ensure their patients are served in a timely manner – contracting with specialists to serve patients inside the clinic or employing telemedicine, for instance.

“It just makes sense sometimes in terms of getting access for the patients, just to have the specialty care take place within the FQHC’s four walls,” she said. “Physicians around the state are willing to give a day a week or every other week to the community health center. It’s partnership for increasing access, and they are paid directly by the health center.”

Cathie Anderson: 916-321-1193, @CathieA_SacBee

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