SAN JOSE — Medi-Cal enrollees in the Santa Clara Family Health Plan may have trouble finding a primary care doctor willing to treat them, leading many to use high-cost hospital emergency rooms and government-funded free clinics — or defer care altogether, a new report from the county’s civil grand jury says.
Compounding the problem — despite a 2015 California law that mandates that all health plans maintain accurate and regularly updated physician directories — the report says the Family Health Plan’s directories are often confusing and out of date.
The report, released Friday, echoes and cites a February 2015 Mercury News story that underscored the shortage of Medi-Cal doctors in the wake of millions of Californians joining the health care program for the poor through a provision of the Affordable Care Act, better known as “Obamacare.”
Under the health care law, the Golden State was one of the first of 31 states that have expanded Medicaid, called Medi-Cal here, to adults without dependent children.
Since January 2014 — when the provision kicked in — about 4 million Californians have enrolled in Medi-Cal under the expansion. Most of the state’s Medi-Cal enrollees are in managed care plans, which requires them to have a primary care doctor who is charge of referring patients to specialists.
In the first three quarters of 2016, the report says, Medi-Cal enrollees in Santa Clara County were more than twice as likely as the privately insured to seek outpatient care at hospital emergency rooms, according to data provided by California’s Office of Statewide Health Planning and Development.
The report suggests that a lack of primary care doctors willing to accept these patients is part of the problem. It noted a UC San Francisco survey last year that indicated only 55 percent of primary care doctors statewide were taking new Medi-Cal patients. Of the doctors surveyed, more than 70 percent cited low reimbursements, payment delays and “administrative hassles’’ as reasons why they stopped accepting Medi-Cal patients.
In Santa Clara County, Medi-Cal patients can enroll in one of two plans: the Santa Clara Family Health Plan or the Anthem Blue Cross Medi-Cal plan. Nearly 80 percent have chosen the Family Health Plan.
Robin Larmer, chief compliance and regulatory affairs officer for that plan, said that as of this month, it has 265,711 enrollees, including 157,093 adults and 108,618 children.
Larmer said the plan has established a partnership with its providers and has a provider network that includes 455 primary care doctors. Of those, she said, 348 — or 76 percent — are accepting new patients.
“It would be nice if every physician would accept Medi-Cal patients, but the reality is that there are disincentives,’’ she said. While she noted that the problem is not unique to California, Larmer said “it’s a pervasive problem and the Legislature needs to hear from consumers and the community that provider reimbursement rates directly impact the access of care.’’
In his revised budget for the upcoming fiscal year, Gov. Jerry Brown last week increased general fund spending for Medi-Cal from $17.7 billion last year to $18.6 billion in 2017-18. But he has been reluctant to increase reimbursement rates.
Nevertheless, Larmer said, “it’s important for our members to have access to primary care physicians and directories that are accurate, and we are certainly focusing on that.’’
The grand jury report recommends that the Family Health Plan help its members by updating provider directories frequently, making it clear when doctors aren’t taking new patients and improving its online “find a doctor’’ tool.
It also recommends that the plan tell members who rely on the printed directory to use it only with help from the plan’s member services specialists, who can verify if a doctor is accepting Medi-Cal patients.
Larmer said the Family Plan has been working “diligently to ensure compliance with (the 2015 law), and we continue to work on that with our print and online directories, and our find-a-doctor tool.’’
She noted that the law requires that the online provider search be updated weekly, but the Family Plan’s is refreshed daily. Likewise, while the Family Plan’s print and PDF directories are updated quarterly in accordance with the law, by July 1 it will be done every month, she said.
Larmer said that if a new member has not selected a primary care doctor, the plan helps to assign one to the patient and also monitors how many enrollees are assigned to each primary care doctor.
The report, written in early 2017, did not address the future of the Affordable Care Act. The House GOP earlier this month voted to repeal and replace it with a substitute that the nonpartisan Congressional Budget Office says would leave 24 million fewer people insured by 2026 than under Obamacare, including millions of Americans covered by Medicaid. The House version, called the American Health Care Act, proposed to end the Medicaid expansion by 2020 and slash Medicaid funding by about $880 billion over 10 years.
Republicans in the U.S. Senate are now beginning the process of drafting their own version of the bill.
May 13, 2017
The Mercury News
By Tracy Seipel
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