Access to Specialty Care

A closer look at four medical specialties in which it is difficult to get consultations for medically indigent patients, especially in the Sacramento area.

"As I am starting to cut back, I have almost more old patients (many going back almost 50 years) who...can't get in with good doctors. I see them and get them in the hands of good doctors for treatment. I can only do so much of this because the younger doctors in the office keep their exam rooms full. The majority of these people I do not charge, but get a lot of sincere thanks."

"I would continue this but I hate taking pills for high blood pressure, etc. (My wife) insists I take more time off for exercise, weight reduction, etc. to get off the pills."

"The overhead is now so great and (with) the abridgement of recompense by insurance companies, Medicare, Medicaid, a lot of orthopedists don't feel they can take any more free cases and feed the family. Many have gone broke or left the area."

A half dozen orthopedic surgeons rotate to provide four hours of free care every other Tuesday afternoon at Sacramento County's Primary Care Center. Four of them volunteer once every 6 weeks, one volunteers once a month and the sixth twice a month. Two of the six are retired.

Under the aegis of SPIRIT, they see the county's medically indigent patients who have been referred for orthopedic consultation and work with and discuss cases with a clinic physician. In 1999 these orthopedic surgeons volunteered 221 hours valued at $23,990 and served 345 patients.

Under the same program is a dermatology clinic for medically indigent patients at Capital Health Center. A dermatologist volunteers four hours twice a month. In 1999 he saw 61 patients in 63 hours, providing services valued at $5,619.

SSVMS is a founding partner of SPIRIT, along with Mercy Healthcare Sacramento, The Robert Wood Johnson Foundation, Sacramento County Department of Health and Human Services, Sutter Health, and UCD School of Medicine.

In addition, a dermatologist is working with others to develop a plan to see uninsured or Medi-Cal patients on his day off. He would accept the Medi-Cal rate if someone contributes space, office and nursing help, and insurance. Another dermatologist spoke of not accepting Medicare assignment, but seeing many Medicare patients at a reduced, even nominal, fee in his office.

These include patients who have grown old with him, but also new patients. He prefers the low fee to the paperwork blitz and hassle.

Specialty societies do not have public positions regarding charity work by their members, but are working in a coalition of 14 statewide specialty organizations and consumer groups to improve access to specialty care. The California Orthopedic Association, the Congress of California Dermatological Societies, the Sacra-mento Valley Dermatological Society, and the California Association of Neurologists belong to that coalition. They gather information and discuss the problems of reimbursement and other bureaucratic barriers to access such as coding and modifiers that complicate billing and reimbursement with Medi-Cal and GMC administrators.

All the specialty societies report that access problems are statewide and are getting worse; all confirm that the problems are especially bad in Sacramento.

A 1998 California Orthopedic Association survey is particularly revealing about the disparity between Medi-Cal payment and actual costs. It included large group practices, small groups and solo practitioners throughout the state, and a Kaiser facility.

On average, every time a patient walks through an orthopedic surgeon's door there is an office overhead cost of $46. For each new patient the cost is $55. This does not include payment to the physician for performing the service or for other physician costs, such as malpractice insurance coverage. The costs in California were the lowest of any in any state surveyed!

Medi-Cal pays $18.18 per office visit for an established patient and $50.50 for a new patient. Thus the average orthopedic surgeon loses $28 on each ongoing patient visit and $5 on each new patient visit-and is paid nothing for the professional service.

For the invasive procedures commonly performed on Medi-Cal patients, the orthopedist's average practice expense and overhead cost is $261 to $396, but Medi-Cal reimbursement ranges from $89 for a finger fracture to $372 for arthroscopic shoulder repair.

Data from DHS show a 2.7 percent increase in orthopedic surgery for the Medi-Cal fee-for-service population in the past year, mostly with a shift from the larger counties to the smaller counties of the state-where there are far fewer orthopedic surgeons!

Neurology and Psychiatry Services
SPIRIT reports no neurology services as part of its medically indigent services program. Except for a neurologist who may see an uninsured, under-insured, or "onerously low-paying" Medicare or Medi-Cal patient as a "favor," neurologists are not seeing low-pay or no-pay patients.

Neurologists sometimes see such a patient in a hospital consultation without charging, but cannot afford to continue with that patient. That increases the pressure for ongoing outpatient neurology service, available only through the UCDMC Neurology Clinic, where the wait for a first appointment is several months.

The newly formed California Association of Neurologists participated in a statewide survey by the California Access to Specialty Care Coalition. About two-thirds of the 94 responding neurologists reported having Medi-Cal patients under treatment.

However, 13 percent wrote off all that care as charity, without billing Medi-Cal and, while one neurologist reported that the GMC program in Sacramento County is working well, others complained of limited access to diagnostic tests and standard imaging.

When SSVMS counties find that medically indigent patients and families need psychiatric assessment and treatment, they refer to publicly funded mental health services.

Such services are "carved out" of Medicare and Medi-Cal reimbursement and of most pre-paid health plans. This not only fragments patient care but also imposes other barriers to access, especially deterring two-way exchange of crucial clinical information.

UCDMC is experimenting with "on-site" psychiatric evaluation and short-term treatment at the county's primary care centers for medically indigent patients. Here, psychiatric residents, supervising faculty and non-medical mental health specialists see the patients and work with the primary care physicians and volunteer psychiatric faculty provide teaching and consultation. Otherwise, psychiatrists are not involved in providing free or low-fee services.

Ed_Rudin@macnexus.org