September 20, 2007
Patients without Doctors: The Flawed Plan of Governor SchwarzeneggerBy Linda Halderman, MD
Arnold Schwarzenegger wants to terminate the problem of uninsured Californians needing better health care. According to Governor Schwarzenegger's Senior Health Policy Advisor, the Governor's Health Care Proposal will add 900,000 Californians to Medi-Cal, the State's version of Medicaid. This expansion of government-funded medicine helps meet the Governor's goal of decreasing California's uninsured population. There is one problem the proposal fails to address, however:
There aren't enough doctors to care for them.
A Math Problem in Sacramento
During a conference with the Governor's Senior Health Policy Advisor and the Deputy Legislative Secretary for California's Department of Health and Human Services, I posed this problem.
"How many more California doctors do we need to accept Medi-Cal to cover an additional 900,000 patients under the Governor's proposal?"
"We're not really sure," came the answer.
"How many doctors are we ‘short' under the current system?" I asked.
There was a pause.
"We don't have that exact information right now."
Surprised but still hopeful, I continued.
"Okay, can you tell me how many doctors in California actually accept Medi-Cal patients?"
"Oh, yes! 35,000 doctors are contracted with Medi-Cal."
"Good. Of those 35,000, how many of those actually treat significant numbers of Medi-Cal patients, as opposed to just being contracted and accepting a tiny number of patients each year?"
Again, silence. Realizing that the information would have to be found elsewhere, I changed the subject.
"Under the Governor's plan, will there be a way to attract more doctors to participate in the program?"
"Absolutely. We're ‘incentivizing' the stakeholders to increase access by raising some reimbursement rates. They might end up just 20% lower than Medicare." [Author's note: Medicare rates in central California are some of the lowest in the region, 20-40% lower than private insurance. Medicare is currently slated for a 10% cut in 2008, followed by a 5% cut for each of the successive six years."]
"Do you know how much rates would have to increase to attract doctors?" I wondered, thinking that at the current Medi-Cal rates, a 10% increase would make a Breast Cancer Surgery consultation worth $26.50.
"We'll have to get back to you on that."
Where Have All The Doctors Gone?
California physician participation in Medi-Cal is the lowest of any State-sponsored program in the United States. Medi-Cal payments to California physicians rank 49th in the country. The rates are based on 1969 data, with only a single increase in 20 years.
Because Medi-Cal reimbursement is often less than the cost of keeping a doctor's office open during the visit (e.g., $24 for a consultation with a Breast Cancer Surgeon, $253 for a two-hour breast-preserving cancer operation and 90 days of care that follows), accepting Medi-Cal destroys the viability of California medical practices. In order to keep their doors open, the vast majority of California doctors must refuse or severely limit the number of Medi-Cal patients they accept.
Under the current system, nearly 60% of patients in the Medi-Cal program report significant difficulty finding a doctor. Wait times are long, particularly for specialists and mental health professionals.
Rural Patients: On the Front Lines
In underserved areas like the rural central California town where I practice, this problem is magnified.
When financial necessity forced me to stop caring for women with breast cancer in September of 2007, I had spent four years operating at a loss. My patient population consisted of 90% uninsured and underinsured women covered only by Medi-Cal or the State's Breast Cancer Early Detection Program. My practice hemorrhaged $10,000-$15,000 each month.
In the weeks before I stopped practicing, I begged the only Breast Cancer Surgery specialist in the region who still accepted Medi-Cal to care for my patients. She serves one afternoon per week, about four hours, at a County-funded clinic 30 miles from my office. She graciously agreed to add my patients to the time slot available and worked hard to expedite the evaluation of women newly diagnosed with breast cancer.
This group of my patients created a six-week waiting list at the clinic. The wait will likely soon reach four months, and is expected to increase when primary care doctors in a 70-mile radius from my practice learn that they no longer have access to a local surgeon.
Patients Need Real Doctors, Not Paper Solutions
California's Governor achieved extraordinary success in the sport of bodybuilding, in the entertainment industry and in business after humble beginnings as an immigrant to the United States without English language skills or financial resources. His accomplishments are the result of hard work, good decision-making and a willingness to see gold where others saw only worthless tarnished metal.
But the Governor's Health Care Proposal does not reflect his brilliant history of success. Instead, he has accepted uninformed opinions and bad advice to craft an idea that has proven impossible before it is even implemented. I hope that Governor Schwarzenegger reconsiders this plan and instead seeks input from those with practical, common sense solutions that serve to improve access to healthcare for California patients in more relevant places than merely on paper.
Linda Halderman, M.D., FACS is a Board-Certified General Surgeon practicing in rural south Fresno County, California.