Nearly half of all doctors in California remain unwilling to treat patients covered by Medi-Cal, the state's Medicaid program, despite extensive efforts in the late 1990s to increase physician participation. Even so, Medi-Cal plans have had little trouble maintaining their physician networks, according to two separate studies released last week by the California HealthCare Foundation's Medi-Cal Policy Institute.
The first report-conducted by researchers at the University of California, San Francisco-found that 56% of primary-care physicians, 55% of specialists and 52% of surgeons in urban areas were seeing Medi-Cal patients in 2001. That's down from 1996, when participation rates were at 59%, 57% and 56% for the groups, respectively.
Even fewer doctors, however, were willing to take on additional Medi-Cal patients, according to the report. In 2001, 55% of primary-care physicians, 48% of specialists and 43% of surgeons who were accepting new patients were accepting Medi-Cal beneficiaries, down significantly from the late 1990s (See chart).
As a result, the number of primary-care physicians available for every 100,000 Medi-Cal patients in 2001 was just 46, one-third less than the 70 available to the general population and below the 60 to 80 recommended by HHS' Health Resources and Services Administration. Medi-Cal patients per capita also had half the amount of specialists and two-thirds fewer surgeons available to them than the general population.
Medi-Cal covers 4.6 million Californians, or about 17% of the state's population.
"Getting care is becoming more and more difficult for Medi-Cal patients," said Christopher Perrone, director of the Oakland, Calif.-based Medi-Cal Policy Institute. "Roughly half of all Medi-Cal patients already report having trouble finding a physician, and it looks like things are worsening."
Declines in Medi-Cal participation could accelerate if California approves a 15% rate cut proposed by Gov. Gray Davis in January, Perrone said. California has the eighth-lowest Medicaid payment rate among all 50 states.
Already, doctor participation is far lower in Medi-Cal than in other states' Medicaid programs. According to the Center for Studying Health System Change, 85.4% of doctors nationwide served Medicaid patients in 2001.
The study also found that California doctors were much more willing to take part in Medicare, which provides payment rates roughly 35% higher than Medi-Cal's. From 74% to 97% of doctors in 11 surveyed specialties had Medicare patients in their practices in 2001, compared with just 28% to 71% for Medi-Cal.
The declines in Medi-Cal participation have come despite a 16% average physician rate hike in August 2000 and ongoing efforts to expand managed care, which healthcare experts predicted would revitalize the program.
In fact, fewer than one in seven physicians surveyed even knew that Medi-Cal had boosted its payment rate over the previous 18 months. Perrone attributed this to the fact that few physicians derive a significant portion of their revenue from Medi-Cal: In 2001, just 25% of doctors provided 80% of all care to Medi-Cal patients.
Meanwhile, dissatisfaction with Medi-Cal managed care has deepened. In 2001, 28% of physicians expressed optimism that managed care would increase reimbursements, down sharply from 64% five years earlier. The percentage of those who said managed care increased the hassles of caring for Medi-Cal patients climbed to 68% from 61% over the same period. Roughly half of all Medi-Cal beneficiaries are enrolled in managed-care plans.
Even so, Medi-Cal health plans have found it relatively easy to attract and retain primary-care physicians, according to the institute's second report, conducted by Mathematica Policy Research, Princeton, N.J.
Nineteen of 29 Medi-Cal plans surveyed in 2002, or 66%, agreed that it was easy to develop and retain primary-care networks, and 71% said renegotiating physician contracts was "not a problem."
Some 76% of Medi-Cal plans, however, said they had at least some trouble maintaining an adequate network of specialists. Orthopedists and neurologists were the toughest to secure, followed by ear, nose and throat doctors, pediatric subspecialists and dermatologists.
Health plans attributed the problem to low reimbursement rates, a general shortage of specialists in certain regions and specialists' perceptions of Medi-Cal patients as being "less compliant and more difficult."