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.
For the Record
Los Angeles Times Monday March 20, 2000 Home Edition Health Part S Page 3 View Desk 4 inches; 110 words Type of Material: Correction
Medi-Cal--A March 13 story in Health incorrectly stated that North Carolina's Medicaid health insurance program reimburses doctors at rates equivalent to Medicare. In fact, that state's Medicaid rates are still lower than Medicare.
Also, a chart that accompanied the story gave wrong figures for some rates paid to doctors by California's Medi-Cal program and by the California Children's Services program. The correct figures below represent rates paid to the University Children's Medical Group at Childrens Hospital Los Angeles for treating cancer patients.
For a lumbar puncture procedure, the reimbursement rates should have been $29.78 for Medi-Cal and $31.27 for CCS. The Medi-Cal reimbursement rate for a needle biopsy of the liver is $41.70; the CCS rate is $43.78.
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.
