Insurance may not fix the health care woes of the poor
By Robin Urevich
California Health Report
Anita Montalbano sits in a cramped back office at Neighborhood Healthcare in the Riverside County city of Temecula. Her job at the safety-net clinic is to get insurance approval for patients who need appointments with specialists. Weeks before St. Patrick’s Day, Montalbano has painted her fingernails green for the upcoming holiday and decked out her workspace with shiny shamrocks. But the lucky clovers appeared to bring no favor to patients waiting to see a specialist.
What matters, she says, is another type of green altogether—how much specialists and the hospitals where they work will get paid for their services. Programs ranging from Medicare to private insurance to county programs for the poor pay for visits for patients who have medical issues requiring a specialist’s care, such as kidney disease, thyroid deficiencies and irregular moles in need of biopsies. The precise amount of payment, however, is not uniform, as it depends on the type of insurance carried by patients.
As a result, many poor patients are not getting the care they need, when they need it. The difference in rates accounts for the wait—sometimes lengthy and never good for their health—that some patients endure. Patients with Medicare or with Blue Shield, Health Net or other commercial plans are first in line for specialty care, followed by Medi-Cal recipients, who sometimes face months-long waits. Dead last are those who rely on county programs for the poor. “It all comes down to insurance,” Montalbano says.
Unfortunately, there isn’t enough health care to go around right now, especially for poor people in Riverside County, an area hit hard by the housing bust and Great Recession. The county cuts a rectangular swath through Inland California, from the city of Riverside and bedroom communities on its western edge through deserts, Indian land, and the rocky moonscapes of Joshua Tree National Park, east to the Arizona border. Refugees from high-rent Los Angeles settled into big tract homes that mushroomed on scrubby land in the boom years of the past decade. Today, three years after the bust, unemployment stands at about 12.9 percent, nearly two points higher than the statewide average of 11 percent.
A new county health plan for low-income residents, Riverside County Health Care, created in January 2012, was expected to ease the economic burden and address health disparities. So far, however, it’s falling short of expectations. The plan promises a full range of medical services: primary care, mental health ser- vices and access to specialists. The idea is that an up-front investment in comprehensive care will have a long-term payoff in fewer emergency room visits and hospital stays.
Riverside County, as well as 46 other counties in California, are in the process of rolling out new health plans for the poor—essentially an expansion of Medicaid—in anticipation of the full implementation of the federal Affordable Care Act in 2014. A signature aspect of the ACA is the expansion of Medicaid to more people. In part, the work that California is doing to prepare early, an effort that is getting significant support from federal funds, is a demonstration project, meant to highlight concerns that other counties in California and other states may face as they implement reform.
It’s an ambitious project, and the on-the-ground realities have been challenging. Even counties with established local health-care plans, like Los Angeles, are scrambling to serve more people with fewer resources.
Only 15 of California’s 58 counties, most of them rural and lightly populated, have fewer primary-care doctors per person than Riverside. Specialists, especially those who will see patients with Medic- aid, are also scarce. Twenty-two community clinics operate in Riverside County, compared to 71 in San Francisco, which is less than half the size of Riverside. It is perhaps not surprising that Riverside County ranks below average in nearly every health outcome, according to the California Department of Public Health.
“Riverside County isn’t the only one that’s struggling,” notes Anthony Wright, an outspoken advocate for health-care reform and the executive director of Health Access, a statewide health-care consumer advocacy coalition. “Care delayed is often care denied,” he says. “Once we get people insured, we have to work on making sure that the coverage is meaningful.”
Health-care reform, in other words, is about more than putting an insurance card in the pockets of low-income people.
Poor patients = long waits
At Neighborhood Healthcare a rainy spring afternoon, a pile of paperwork and a full load of patients jammed Dr. Sarah Russell’s schedule. But the 30-something primary-care doctor took time after work to point out how her patients have been denied critical care.
Take the case of a 55-year-old man born with a single kidney. Dr. Russell diagnosed him with stage-two kidney disease and referred him to the county hospital’s nephrology clinic.
“He has one kidney,” Dr. Russell says, “and that kidney is not working. If he doesn’t get proper care, he could end up on dialysis a lot sooner.” He also could develop a host of other debilitating symptoms like chronic fatigue, pain and dizziness. Still, the hospital refused her referral, saying that only patients with stage four or five kidney disease, whose sole option by then is dialysis or kidney transplantation, are accepted in its nephrology clinic.
Part of the difficulty with health-care reform in Riverside County lies with the county hospital itself, which has appeared to put paying patients ahead of its poorest and most fragile, who sometimes wait more than a year to get the care they need, say critics of the system.
The county hospital, Riverside County Regional Medical Center in Moreno Valley has long made it tough for patients who have relied on the county’s pre-re- form insurance program for the medically indigent to see specialists, says Neighborhood Healthcare’s Montalbano. Riverside, like most California counties, is the provider of last resort for emergency medical care for the poor. Dr. Russell’s patient, though, was signed up for River- side County Health Care, the new and improved insurance program.
Riverside County Department of Public Health spokesperson Jose Arballo says that specialists are available to consult with primary-care doctors and are open to reconsidering their denials.
That hasn’t been Dr. Russell’s experience, she says. Montalbano points to two more members of the county’s low-in- come health plan whose referrals were recently rejected. A colon cancer screening for a 55-year-old man, ordered by his doc- tor, was denied because Riverside county hospital resources don’t permit such tests, even though they are recommended for patients 50 and older. A 56-year-old woman with an atypical mole on her hand will have to wait and see if hospital dermatologists will agree to remove it. Her doctor must biopsy the mole and provide additional documentation before arguing the patient’s case again.
“They have their guidelines that are so restrictive,” Dr. Russell says. “This is the hardest county I’ve ever worked in.”
County officials say the six-month-old program is so new that they are still working out the kinks. It will eventually cover some 20,000 low-income adults. One of the plan’s major promises is that it will provide what is known as a “medical home,” which for patients is a more seamless and preventive approach to care helmed by a primary-care physician. Instead of bouncing from doctor to doctor with no one keeping an eye on the patient’s overall health, each patient in the new system would be assigned a single doctor who manages the full array of treatment.
But that model will work as designed only if patients have access to specialists. That’s not happening currently. To illustrate that point, Montalbano pulls out a well-worn sheet of paper encased in a clear plastic folder. It shows wait times for the county hospital’s specialty clinics. The longest, at 16 months, is for cardiology, closely followed by nephrology and gastroenterology at 14 months, with neurology at a year. Referral clerks at other clinics report waits of six to 12 months for specialist care.
These referral rates are out of compliance with state standards, which require the county to provide most specialty-care appointments within 30 days. The county has 60 days to make dermatology and gastroenterology appointments because of the shortage of specialists in those areas.
County health department spokesperson Arballo insists that the county has complied with these rules. But Letty Perez, manager of the Temecula Neighborhood Healthcare clinic, disagrees. Members of the new plan for low-income people appear to be facing much longer waits, she says. “We were all excited thinking they will get in a lot sooner. But it seems about the same.”
Dr. Lawrence Clark, a Riverside neurosurgeon, says that one reason for the epic time lags is that higher paying patients crowd out those who depend on county programs. “The neurosurgeons who work out of that facility also want to make money and see workers’ comp and personal injury patients in addition to Medi- Cal and uninsured patients,” says Dr. Clark. “There’s a bit of competition for their services and time.” Hospital administrators, he adds, want it that way. “The administration wants the hospital to be profitable,” he says.
Dr. Clark and three partners ran the county hospital’s neurosurgery clinic from about 1992 to 2001 and got patients in quickly, he says. Although they also saw higher paying patients at other hospitals, they exclusively treated low-income patients at the county hospital.
Not all specialists share Dr. Clark’s view of the allocation of care. Dr. Silvio Hoshek, a neurosurgeon who currently practices at the hospital, insists that all his patients—about 60 percent of whom have insurance—are treated quickly now, regardless of who pays for their care. (Riverside County Regional Medical Center CEO Douglas Bagley declined repeated interview requests and didn’t answer e-mail questions that were about access to specialty clinics.)
Still, one endocrinologist, who asked not to be named, acknowledged that waits are a big issue in his clinic. That’s why he has refused to see paying patients at the hospital. He also refused a hospital request to give priority to county employees insured by the county health plan, Exclusive Care.
Now, both he and Dr. Hoshek note, the county hospital may be moving away from its policy of allowing doctors to treat private patients at the hospital.
Long delays for specialty-care appointments also have an effect that’s antithetical to the logic of health-care reform. When family practice physicians are left to manage complicated diseases without help from specialists, patients resort to emergency room care to ease their symptoms. This is both costly and, in many cases, ineffective, even dangerous, for the patient.
Fifty-eight-year-old Chris Hernandez, newly enrolled in the county’s plan, visited two emergency rooms in as many weeks. His pain from two hernias, he explained to the clerk who signed him up, was constant and intense. It was an 11, he joked to health-care providers, on the one to 10 pain scale that health-care workers use. Uninsured on and off for years, Hernandez went as long as he could before seeking care. His boss on a Caltrans landscaping crew noticed him wincing in pain and laid him off last fall, saying it was too dangerous for him to work.
Severe pain is a criterion for an urgent primary-care appointment under River- side County Health Care. But Hernandez soon learned that, despite his new insurance, it would take more than a week to get into a clinic near his home in the Coachella Valley town of Indio. So before the ink was dry on his insurance card, Hernandez headed for the county hospital emergency room, where he got pain pills and other medication.
But he developed a raging allergy to the pain medication. “I was scratching like a monkey,” Hernandez says. He stopped taking it and hoped he’d finally get relief at his primary-care appointment. Hernandez waited and then ran headlong into another obstacle. His doctor prescribed alternative medication for pain, but Hernandez learned he’d either have to journey 60 miles to Riverside to get it or have to pay out of pocket.
Riverside County covers an area nearly the size of New Jersey, and patients in far-flung areas who can’t get drugs by mail face treks of up to 150 miles to pick up prescriptions. Riverside County Health Care does have a prescription drug-by-mail plan for members, but pain medicine is excluded because of the potential for theft. Again unable to stand the pain, Hernandez visited another emergency room, at Eisenhower Medical Center near his home.
Last summer the county released a re- quest for proposals for pharmacy services and received no bids, reports Arballo, the county health department spokesperson. The county is currently in talks with a commercial pharmacy, he says, and hopes to solve the problem.
As for Chris Hernandez, after a frustrating three-month struggle, an end is finally in sight. He has an appointment with a surgeon. Better yet, his blood pres- sure and diabetes are under control, thanks to his work with a primary-care doctor at the Indio clinic, who says he’s fit for surgery.
Riverside County Regional Medical Center CEO Bagley said in an e-mail that, although imperfect, the low-in- come health plan represents a step for- ward for previously uninsured patients. “It’s a major improvement,” he wrote, “especially given that funding is extremely limited.”
But the entire burden for the spotty care for the poor cannot be laid at Riverside County’s door. Other culprits are razor-thin budgets, a sluggish economy and the most severe physician shortage of any other urban county in California. “I would be the last person who’s an apologist for the system and what it costs,” Health Access’s Wright says of the crises that counties are facing. “But the kind of cuts we’ve seen in state and the counties have been with a meat ax.”
Some argue that the best hope for a solution to the county’s health-care issues lies on the grassy expanse of the University of California, Riverside, campus, where Dr. Richard Olds is struggling to open what could be California’s first new public medical school in 40 years.
“The first thing the medical school will do is hire more primary-care doctors,” says Dr. Olds, dean of the school, noting that those faculty members will also practice in the community. By 2014, the school’s residency programs will send more than 150 newly minted physicians, more than half of them in primary care and internal medicine, to train in clinics throughout Riverside County. Dr. Olds cites studies showing that 40 percent of doctors set up shop where they served their residencies, a hopeful finding for Riverside.
But Dr. Olds needs $100 million, or commitments of $10 million annually over 10 years, to get the school off the ground. Last year, he was forced to put plans on hold when the $15 million in state funding he counted on was snatched away, a casualty of the budget squeeze. So Dr. Olds took his case to whoever would listen. Most of the funding has come from local health-care institutions. The bulk of the money is pledged, and once the commitments are all in, he’ll apply for accreditation. He hopes to admit his first class in August 2013.
In Riverside County, where getting basic health care is a struggle for many, the hardscrabble beginnings of its first medical school seem somehow fitting. If the school is successful, it might eventually be the salvation of a cash-strapped region of the state where health outcomes are worse than average.
But no such cure is on the horizon for other parts of the state suffering from similar problems. Relief won’t come only from minting new doctors. “It’s been very clear,” Health Access’s Wright says, “that if we’re trying to provide more care in the same way to lots more people, we just can’t do it.”