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HOME > ABOUT > PRESS > SPECIALTY CARE IN SONOMA COUNTY
Article published - September 20, 2007
Credit: SONOMA MEDICINE
Specialty Care for the Un- and
Underinsured in Sonoma County
By Jeff Sugarman, MD, and Kelly Pfeifer, MD
Years ago, many specialists in Sonoma County routinely did a small percentage of pro bono work in their offices. Today, they are often reluctant to see Medi-Cal and other underinsured and uninsured patients, for a variety of reasons. These include poor reimbursement, complicated paperwork for authorizations and prescription drugs, high “no-show” rates, and language barriers. In addition, predatory HMO contracting has contributed to the division of physician communities. Specialists who continue to see Medi-Cal patients end up being the only ones in their specialty doing so, resulting in burn-out.
Specialty access for the un- and underinsured appears to be reaching a tipping point. In his recent article, “10,000 Referrals With Nowhere To Go” (Sonoma Medicine, Summer 2005), Dr. David Gorchoff asks, “What would it take for you specialty physicians to get involved in caring for these patients?” The answer is complex, in part because the barriers to care differ among specialties, and in part because services, infrastructure and dollars in Sonoma County health care are so much in flux.
This article describes the barriers to accessing specialty care in Sonoma County and proposes
some solutions.
Barriers
Without a doubt, the most significant barrier affecting access to specialty care is poor reimbursement (see Table 1). One important piece of advice routinely offered in practice-management courses is for the physician to audit the payer mix and drop the lowest payer. Medi-Cal is almost always the lowest payer. For example, Medi-Cal pays only $24 for a routine adult follow-up visit (CPT code 99213). This reimbursement is less than half of what Medicare pays ($60) and less than one-third of what private medical groups typically pay (about $75).
With Medicare and private insurers, specialists usually collect more for a consultation visit (when the patient is referred by a primary care physician) than for a non-referral new patient visit. Medi-Cal, however, sees little difference between the two types of visits. For example, Medi-Cal pays $57 for a level-3 new visit (99203) and only $59 for a level-3 consultation visit (99243). In contrast, Medicare pays $93 and $124, respectively.
For procedures (the specialist’s lifeblood), Medi-Cal reimbursements are also very poor. Excision and repair of a malignant lesion (11602 and 12032), a dermatology procedure that may take 40-50 minutes, gets only $176 from Medi-Cal, compared to $459 from Medicare.
When a Medi-Cal patient turns 65 and is eligible for Medicare, the patient’s access to specialty care does not really brighten. Although Medicare will pay 80% of allowed charges, Medi-Cal pays zero in this setting. For a specialist, this arrangement is essentially like accepting a contract that pays 80% of Medicare. In an environment where the costs of running a practice are increasing and reimbursements are decreasing, specialists complain that they actually lose money every time they see a Medi-Cal patient.
Furthermore, Medi-Cal patients’ cards are frequently out of date, so Medi-Cal will not cover the visit. Office resources are then used to try to collect for the services provided. Although some offices are able to check the patient’s Medi-Cal status online at check-in, this effort requires additional staff time and resources. If the card is not current or valid, the patient will have to pay cash or is turned away. Usually the patient decides not to be seen, leaving an unfilled spot on the schedule, for which the specialist collects nothing. All of these factors contribute to the economic inefficiency of seeing Medi-Cal patients.
Solutions
How can we expand access when so many specialists are struggling to stay afloat? We need to look at creative ways to increase supply, decrease waste, and reduce inappropriate allocation of resources. Many strategies are already in place.
Community clinics have tried to address the access problem by hosting specialists on-site, which in some cases has created a “hub” for a particular specialty at a certain community clinic (see Table 2). The clinic can decrease the “hassle factor” associated with Medi-Cal patients. Patients seen at the clinic are less likely to no-show, language interpretation is available, and the clinics manage all the scheduling and billing. Some specialists volunteer, although most are paid an hourly rate ($100/hour is typical).
On-site specialty clinics can work financially because the community clinic is usually paid more to see a Medi-Cal patient than if that patient were seen in the specialist’s office. The same $24 office visit mentioned above is often paid at over $100 by Medi-Cal if the patient is seen at a community clinic. Strangely, Medi-Cal does not seem to care what the patient is seen for, how complex the medical issues are, or how much time is spent: the reimbursement is the same. A three-minute suture removal, for example, is paid the same as a 30-minute full skin check that involves four biopsies. Medi-Cal designed this reimbursement system for clinics in recognition of the higher costs incurred by their complicated population (e.g., need for ancillary services in case management, outreach, mental and behavioral health, and health education) and to simplify billing.
Despite better reimbursement and less hassle, there are still barriers to delivering much-needed specialty care in community clinics. The clinics, for example, are limited by lack of space, staff, and funding. Without specialty supplies and appropriately trained staff, specialty management in clinics can be frustrating and less efficient. If the specialty clinic visit leads to the need for a procedure in a hospital or surgery center, questions arise about who will provide and pay for the resources. Follow-up and liability are also concerns.
Fortunately, there have been some creative responses to these problems from the specialty community. Local gastroenterologists, for example, have established a GI clinic at the Southwest Community Health Center in Santa Rosa. The clinic operates for a half-day each Tuesday. The six participating gastroenterologists (out of about a dozen in the county) rotate at the clinic, each working one half-day every six weeks. They are paid hourly. Any procedure generated during a clinic is the responsibility of the specialist who saw the patient. Procedures (mainly colonoscopy and endoscopy) are done at Memorial Hospital. These gastroenterologists surely could make more money by eschewing the clinic system and only seeing fully insured patients in their offices, but they have chosen to do otherwise.
Another response has come from local dermatologists, who serve uninsured and Medi-Cal patients at the Alliance Medical Center in Healdsburg. Their dermatology clinic offers comprehensive care every Thursday. Six dermatologists (out of more than 20 in the county) rotate at the clinic. Some work a half-day every month; others work three or four shifts a year. Some are paid; others volunteer. Sutter residents regularly rotate through the clinic and are precepted by the dermatologists. This arrangement serves the educational needs of the residents and allows more patients to be seen, decreasing the high demand and helping the clinic’s “bottom line.”
The dermatology clinic also has a highly trained physician assistant. She triages the referrals, sees patients, follows up on biopsy results, and makes sure the clinic is adequately supplied and efficiently run. Lastly, the clinic pharmacy is stocked with many common dermatology medications, eliminating the need for cumbersome TARs for Medi-Cal patients and providing affordable medications for uninsured patients.
Kids’ Net (see accompanying article) has closed the gap of services for un- and underinsured children by creating a network of specialists who commit to doing a certain number of visits a year. The success of Kids’ Net reflects the willingness of community physicians to pitch in, as long as they know that by opening the door, they won’t be deluged. Kids’ Net carefully case-manages the referrals to help overcome transportation and language barriers. The case managers also ensure that no doctor is asked to do more than his or her initial commitment.
Some of the community clinics have addressed the specialist shortage by hiring their own specialists and having those specialists rotate through multiple sites as a full-time job. This “circuit rider” system is in place for psychiatry, gynecology, and pain management, and is being explored for other specialties as well.
What’s Ahead
The future holds many promising solutions to specialty access for the un- and underinsured, including managed Medi-Cal, e-mail consults, an ophthalmology clinic, evidence-based guidelines, telemedicine, and health system reform.
- Managed Medi-Cal may help when it arrives in mid-2008 (see accompanying article). The manager, Partnership HealthPlan of California, has been operating in Napa, Yolo and Solano counties for several years, and their specialists report high satisfaction and much better rates with the system.
- A network of specialists willing to be “e-mail consultants” could be developed to help manage patients who don’t need to be seen in person. HIPAA concerns can be alleviated by using medical record numbers instead of names.
- Local ophthalmologists are trying to establish an “eye hub” at one of the community clinics but have so far been stymied by the cost of equipment (up to $5,000) and the lack of space.
- Evidence-based guidelines and protocols can be used to decrease unnecessary referrals, and to help primary care providers navigate through initial management. A centralized website could be used to confidentially upload histories, studies, and X-rays for specialists to review.
- Telemedicine has been used in many sites, either live or “store and send,” and it works well for non-procedural visits. Patients can receive comprehensive evaluations within the clinic, and the specialist can review the information whenever convenient. Furthermore, telemedicine consults are reimbursed by Medi-Cal.
- The pending closure of Sutter Medical Center has precipitated tremendous interest in redesigning our health system. Local providers, for example, have formed the Sonoma Health Access Coalition with a vision of expanding access to early intervention and prevention.
Conclusion
Lack of specialty access for un- and underinsured patients leads to poor quality of care and high costs. We physicians have an opportunity to create a comprehensive solution, not just another patch on a broken system. We can work with community partners—such as the Sonoma Health Access Coalition, the Department of Health Services, local hospitals, and SCMA—to help these visions become realities.
On-site specialty clinics, e-consults, and circuit-rider options are already being implemented. With grant funding, we can develop a comprehensive web-based system, perhaps including subsidies for specialists seeing uninsured patients (as is done in San Francisco). Ultimately, the solution will require a greater financial commitment from state, federal, and philanthropic sources, as well as increased efficiencies in providing specialty care.
With creative solutions and the participation of local specialists willing to share the burden, we can devise a better medical system for everyone.
Dr. Sugarman, a Santa Rosa dermatologist, helped establish the dermatology clinic at the Alliance Medical Center. Dr. Pfeifer, a family physician, is medical director of access for the Redwood Community Health Coalition. Both serve on the SCMA board of directors.
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