Who Will Give That Special Care?

A health care crisis appears to be building for California’s poorest, most vulnerable youngsters, who often must wait months or travel long distances to see pediatric specialists in such critical areas as orthopedics and neurology.

With Medi-Cal paying physicians some of the lowest reimbursement rates in the nation, increasing numbers of children’s doctors are limiting their participation in the insurance program for the poor and disabled. Even though they’ve traditionally treated a mix of privately insured, government-insured and uninsured patients, many complain that the Medi-Cal payments don’t even cover their costs.

Some pediatricians and pediatric specialists say they found the Medi-Cal bureaucracy so daunting and the economics so skewed against them--like $16 for a basic office visit with a cancer doctor at Childrens Hospital Los Angeles--that they moved their practices out of the state. Many others are simply turning down offers to work in California.

Medi-Cal officials acknowledge the low reimbursement rates within the program but say health care is competing for limited dollars in a state with millions of poor residents. “It’s always a question of priority-setting,” said Stan Rosenstein, a state health department official who oversees Medi-Cal, the state’s version of the federal Medicaid program. The state and federal governments share Medi-Cal’s costs.

Although few hard numbers exist on the growing shortage of pediatric practitioners, the impact is being felt at the academic medical centers and children’s hospitals that accept patients regardless of their health coverage.

At UC Davis, for example, “the primary-care pediatricians in the university do not have enough staff to pick up on all the follow-ups of the emergency-room visits,” said Dr. Robert L. Black, a California official with the American Academy of Pediatrics.

Such hospitals, with their concentrations of specialists, offer cutting-edge services unavailable elsewhere.

But the shortages could ultimately affect other young patients with special needs, even those with higher-paying insurance, as they are forced to wait for examinations and procedures.

Childrens Hospital Los Angeles is among those feeling the crunch. “If you get more and more patients and no additional staff, you get delays in diagnostic studies, medical attention, surgical attention,” said Dr. Stuart Siegel, head of the pediatric hematology and oncology department. “For things short of life-and-death, there are differences in the intensity and the promptness of the care patients are receiving. For cancer and life-threatening diseases, it hasn’t quite gotten to that point.”

Until now, Siegel said, his hospital was able to accommodate the low reimbursement for Medi-Cal recipients, who make up about 70% of its patients.

But the shrinking supply of pediatric specialists has increased the Medi-Cal load on such hospitals, and as a result, revenues aren’t covering the costs of care and the hospital can’t afford the best young doctors. “Here’s California, one of the richest states, with the biggest population, and we are putting ourselves in the position of having a much-inferior medical system,” Siegel said.

The pediatric squeeze is acutely felt in Medi-Cal fee-for-service plans, which cover children in smaller counties that haven’t moved to managed care, foster children and those with illnesses such as asthma and diabetes. The problem is even worse, advocates say, among the 145,000 seriously disabled children who get their specialty care through California Children’s Services, a fee-for-service plan that pays only slightly more than Medi-Cal rates.

When these fee-for-service patients can’t find a doctor, they turn up at emergency rooms.

Over the past few years, the state has been moving many of its 5 million Medi-Cal patients (about half of whom are children) into managed care, which was designed to cut back emergency-room use and ensure access to primary-care doctors. Although primary-care access has improved for many, the difficulty in getting services from pediatric specialists persists.

Shortfall Isn’t Limited to Children

Betah Osthimer, an attorney with San Fernando Valley Neighborhood Legal Services, which helps the poor find medical care, said the problem getting children to specialists is part of a larger issue of getting care, even for those with insurance.

“Even having a [Medi-Cal] card doesn’t guarantee you access,” Osthimer said. “The card is just an entree.”

That’s very clear to Jennifer Gonzales, an Antelope Valley mother of four, whose 6-year-old daughter, Sabrina, suffers from scoliosis, a curvature of the spine.

When Sabrina first was seen by a Medi-Cal HMO in Lancaster at age 3, she was fitted for a back brace. But the family moved to Palmdale and was told their health plan would no longer serve them. As Sabrina outgrew the brace, her mother struggled fruitlessly to find a local doctor who would accept Medi-Cal. During that time, the child’s condition worsened.

“There was nobody out here who would see my daughter on Medi-Cal. If they did take Medi-Cal, they were full. I was lost and didn’t know what to do.”

So Gonzales moved her family back to Lancaster and rejoined her old HMO, where office waits often reached three to five hours but where her daughter received some care.

By the time she returned to Palmdale, several HMOs had begun serving Medi-Cal patients in that area. Her plan wanted Sabrina treated by one of the plan’s general orthopedists.

In November 1998, Gonzales won permission to have Sabrina see a doctor outside the health plan’s network at Childrens Hospital Los Angeles, more than 50 miles away. Since then, doctors have operated twice on Sabrina to put rods in her spine.

Many families are unable to obtain such care for children with serious conditions, say parents and advocates across California.

“We get calls from families all the time asking us for names of doctors, especially pediatric specialists in the [Antelope] Valley. There are none,” said Toni Gonzales (no relation to Jennifer), who works with Families Caring for Families to help parents navigate the system.

Pinch Is Being Felt in Cities

Finding a doctor can be just as difficult in urban areas as in more rural regions.

“We have problems in the inner city,” said Lynn Kersey, director of Maternal and Child Health Access, a downtown Los Angeles organization that advocates for low-income families. She cited the example of a child referred across town to a Beverly Hills podiatrist and told to pay out of pocket for removal of scar tissue that was restricting foot movement because his health plan lacked podiatrists within the area.

Access to pediatric specialists is worsening as California hospitals and health plans encounter problems recruiting and retaining doctors in a state with a very high cost of living and very low Medi-Cal reimbursements.

“We’re 51st in the country, below the District of Columbia,” said Dr. William Byrne, medical director of Children’s Hospital Oakland and a member of a medical coalition lobbying for better reimbursement.

Ten to 15 years ago, it was easy to bring young doctors to California. “Now, it can take two to three years to recruit somebody,” he said. To doctors looking for a place to practice, “all of a sudden Iowa looks good.”

Losing ‘the Best and Brightest’

At Childrens Hospital Los Angeles, Siegel bemoaned losing one of the “best and brightest” pediatric surgeons to North Carolina, which recently adopted Medicaid rates equal to those of Medicare, the federal health program for people 65 and over. Medi-Cal sometimes reimburses doctors only a third of what Medicare pays for treatment of older adults with similar disorders.

Dr. Duncan Phillips, a California native now practicing at the University of North Carolina, Chapel Hill, said he moved reluctantly. At Childrens Hospital, “the variety of cases I was able to do and the variety of disease I was able to take care of was clearly superior to anything in the country. But practicing medicine in California is probably more difficult than any other state.”

He cited low Medi-Cal reimbursements, 12- to 18-month payment delays and waits for surgical approvals. He said it could take up to six weeks for the go-ahead to remove gallstones, during which time he would have to tell a teenage patient, “I’m sorry, you will have recurrent attacks of pain and you will not be able to attend school and you will throw up and there is nothing I can do about it.”

In Los Angeles, he said, he worked night and day and performed 600 operations a year to support his family. “Here I do 400 a year and I can see my family.”

Phillips also called paying $500 for a retiree’s appendectomy under Medicare but just $320 for a 6-year-old’s appendectomy under Medi-Cal “a form of discrimination, like children aren’t worth as much as grown-ups. They don’t vote. A lot of Medi-Cal moms are not wealthy enough to hire lobbyists to go to Sacramento.”

In pushing for higher reimbursements, the Specialty Care Coalition, with support from the California Medical Assn. and the American Academy of Pediatrics, said consequences of low rates and shortages will spill over to all sick children.

“One of the things it’s hard to convince people is we’re not just talking about access for poor kids. We’re talking about access for everybody’s kids. You may have the greatest insurance in the world, but there will not be a subspecialist available to see you,” Byrne said.

Black, of the American Academy of Pediatrics and a general pediatrician in Monterey, put it bluntly: “If you have only one cardiologist to see 700 kids, even the kids whose parents are paying out of pocket” will wait.

A lack of statewide statistics makes it difficult to quantify the specialty crisis, but government officials, doctors and advocacy groups are hearing of problems.

“As director of the [California Children’s Services] program, I’m very concerned about having an adequate network of providers in which to refer our children with conditions that need these subspecialists,” said Dr. Maridee Gregory, chief of the children’s medical services branch of the California Department of Health Services. The agency is looking at a variety of options to address the issue, she said.

Some Care Plans Pay Extra to Secure Services

While doctors await solutions, health plans in several counties are paying extra to ensure that poor children’s complicated health needs are met.

Dr. Helen DuPlessis, chief medical officer of L.A. Care Health Plan, which oversees Medi-Cal managed care for the county’s poor, said some plans in Orange and Sacramento counties have been forced to contract with specialists at reimbursement rates that are 140% to 200% of fee-for-service prices.

Rosenstein, the state’s acting deputy director of Medical Care Services, said that although Medi-Cal rates have gone up incrementally, California is still hampered by budgetary restrictions.

“There were a significant number of years where the economy was bad, and there was no sufficient budgetary money to provide rate increases. We’ve taken steps to improve that,” he said.

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Additional Resources for Pediatric Care

The California Department of Health Services recommends that Medi-Cal recipients having problems with their plans first call the member services department listed on the health plan membership card.

Other resources for help in obtaining pediatric specialty care:

* California Department of Health Services, Medi-Cal Managed Care Office of the Ombudsman Program, (888) 452-8609.

* Health Consumer Center of Los Angeles, a project of San Fernando Valley Neighborhood Legal Services, (800) 896-3203. Helps low-income Los Angeles County residents with health-care access.

* Maternal and Child Health Access, (213) 749-4261. Will help with access and enrollment in health programs and assist with problems.

* The Alliance for Children’s Rights, (213) 368-6010. Provides legal services for children on Medi-Cal and for foster children; will help locate Medi-Cal providers.

* Protection and Advocacy Inc., (800) 776-5746. Provides legal services and information on medical access issues.

* Family Voices California, (213) 380-0008. An advocacy group consisting of parents of children with special health needs who provide support and information to other families.

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TREATING KIDS: HOW DOCTOR PAYMENTS VARY

Some doctors and health advocates complain that the state pays too little for poor children’s medical care. Figures provided by a Los Angeles doctors group compare the rates pediatric cancer specialists receive for seeing Medi-Cal patients to rates for patients covered by other government programs. Rates are for patients seen in hospital-based practices.

Description

Office visit / Low complexity

WHAT THEY CHARGE: $78

WHAT THEY GET

Medi-cal: $15.84

CCS*: $16.63

Medicare: $36.16

*

Office visit / Moderate complexity

WHAT THEY CHARGE: $110

WHAT THEY GET

Medi-cal: $26.40

CCS*: $27.72

Medicare: $58.22

*

Office visit / High complexity

WHAT THEY CHARGE: $144

WHAT THEY GET

Medi-cal: $44.00

CCS*: $46.20

Medicare: $93.37

*

Description

Chemotherapy (spinal)

WHAT THEY CHARGE: $160

WHAT THEY GET

Medi-cal: $50.35

CCS*: $52.87

Medicare: $101.20

*

Description

Chemotherapy (intravenous)

WHAT THEY CHARGE: $61

WHAT THEY GET

Medi-cal: $10.66

CCS*: $11.20

Medicare: $45.01

*

Description

Lumbar puncture

WHAT THEY CHARGE: $138

WHAT THEY GET

Medi-cal: $21.56

CCS*: $22.64

Medicare: $73.01

*

Description

Needle biopsy of liver

WHAT THEY CHARGE: $551

WHAT THEY GET

Medi-cal: $37.74

CCS*: $39.63

Medicare: $121.84

*

*California Children’s Services is a state-sponsored fee-for-service plan that provides specialist care for kids with severe medical problems.

*

Source: Dr. Stuart Siegel, University Children’s Medical Group at Childrens Hospital Los Angeles; the Children’s Specialty Care Coalition