Why Medi-Cal Makes Doctors Sick

Money, paperwork and stigma

Rosa, 18 years old and 13 weeks pregnant, applied for Medi-Cal but wasn't accepted into the program until 21 weeks later, precariously close to her due date. Not only did Medi-Cal's cumbersome paperwork present a challenge, but Rosa (not her real name) was treated contemptuously by Medi-Cal workers.

And most doctors are no more enthusiastic about Medi-Cal.
"Medi-Cal recipients were far more likely to miss appointments than other patients," says Berkeley acupuncturist Jay Sordean, who stopped seeing Medi-Cal patients in 1987 after treating them for four years. "And 10 to 15 percent of them failed to appear or didn't bring the necessary Medi-Cal identification."

"Medi-Cal insists a patient have an ongoing ulcer for me to prescribe medication," says one frustrated doctor. "But often the patients need the drugs to prevent the ulcer from reappearing." To medicate patients, the doctor often relies on pharmaceutical company handouts. Other doctors simply deceive the system. "Doctors frequently lie to Medi-Cal, concocting whatever diagnosis is necessary to secure the proper drugs," one physician says.

The 3-decade-old program was supposed to put the state's poor on equal footing with mainstream society, affording them access to private health care. Instead, it has alienated physicians and turned its 5.4 million beneficiaries into medical pariahs.

According to a University of California at San Francisco study published in the February Western Journal of Medicine, only 31 percent of 124 physicians surveyed statewide are willing to accept new Medi-Cal patients. In focus groups conducted by the authors of the article, doctors describe their strategies to avoid Medi-Cal recipients. Some outright refuse to see these patients. Others have medical residents provide care, transfer the patients to public hospitals or treat the patients in the emergency room -- but refuse to provide follow-up outpatient care.

As one focus group doctor says, "The best strategy -- no, I'm sorry, my strategy -- is I don't see them in my office."

The source of the medical discontent is money: An early '90s study by the state's Little Hoover Commission determined that California pays "a lower cost per Medi-Cal user than the next 12 largest states in the nation, and California's taxpayers pay a smaller share of their income to support the program when compared to the national average. And this despite the fact that California has a higher percentage of its population receiving Medicaid than the next 12 largest states."

Although Medi-Cal dropped $14 billion on services in 1993, the director of the California Department of Health Services, Molly Joel Coye, conceded that year that "these services are not provided in a system that makes sense."

"Thousands of Medi-Cal beneficiaries are hospitalized each year for serious health conditions that could have been prevented by primary care," Coye wrote. "Instead of being cared for in a doctor's office or clinic, our patients wind up waiting hours in emergency rooms for simple problems like a child's ear infection."

The Little Hoover Commission concurred with Coye's critique, noting that because Medi-Cal failed to provide crucial preventive care for the poor, it ended up spending much of its money on catastrophic care, and was also increasingly becoming "the payer of last resort for those who are made poor by illness, such as people in nursing homes or patients with AIDS."

Funding for Medi-Cal is split almost evenly between the federal government and the state, and the program serves three main groups: categorically needy people, who receive Medi-Cal because they qualify for a major public assistance program; medically needy (people aged, blind or disabled whose income is too high to qualify for public assistance); and medically indigent (generally individuals under 21, pregnant women and persons in long-term facilities for non-age-related reasons).

San Francisco psychologist Steven Korn accepted Medi-Cal patients for more than six years, but stopped billing the program in mid-1994 when it became too much of a hassle. Like many doctors, he complains of a dizzying trail of paperwork. And Medi-Cal was stingy. It would pay "something like $29.74 for a $100 session," he says.

In the Little Hoover Commission study, one midlevel Medi-Cal official alleged that reimbursement rates had "dropped so low in California that in many instances they are not covering the overhead of medical providers."

"I still see Medi-Cal patients," says Korn. "They make up approximately 20 percent of my practice. But it's pro bono work."

Berkeley gastroenterologist John Roark, who treats Medi-Cal patients, isn't surprised by physicians' resistance to Medi-Cal.

"Most physicians are Republicans, far right-wing. Their attitudes are often Neanderthal," Roark says. "They really aren't very bright about social issues, not overly sensitive to racial issues." He says doctors often don't want these Medi-Cal patients in their waiting rooms because they're prone to disruption because of drug and alcohol abuse.

The Western Journal of Medicine article finds that doctors also reject Medi-Cal patients because they believe these patients are "more likely to sue, aren't grateful for care, are less likely to follow the physician's advice, and have complicated psycho-social problems." It recommends that medical schools recruit more minorities because of its finding that minority physicians are more apt to accept Medi-Cal patients. Yet minority physicians whose patient base is made up largely of Medi-Cal recipients are made vulnerable by those low rates, placing some of their practices perilously close to collapse. Will freshly minted minority physicians merely bypass the Medi-Cal patients in the inner city for more lucrative territories?

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