Nearly one million San Diego County residents — that’s nearly one in three — are on Medi-Cal, the federal/state health plan for low income people, so it’s important that there are enough doctors willing to accept them as patients.
This explainer is part of a larger story about Medi-Cal doctor shortages in San Diego.
But a new survey says the county has a shortage of both primary care doctors and, especially, specialists who are willing to see these beneficiaries. That’s translated to long wait times and long travel distances for patients who need prompt care.
inewsource spoke with Dr. Jim Schultz, chief medical officer with Neighborhood Healthcare in Escondido, about the problem he sees when Medi-Cal patients need follow-up care. His team which sees large numbers of the county’s lowest income patients, often has to struggle to find them an appointment with a specialist.
The following interview was edited for clarity and brevity.
Dr. Schultz, San Diego County now has nearly 1 million people covered by Medi-Cal. That’s about 160,000 more than it had two years ago. You’ve really had to absorb a lot of the load.
Here, just in primary care, we’ve really had to ramp up a lot. We’ve crammed people into closets and bathrooms to make additional exam rooms and office space just so we could handle it.
We were seeing a lot of these patients before, but what happened was the patients who were previously unfunded now have Medi-Cal (in part because of the Affordable Care Act). Services we were trying to get them to do before, like MRIs (magnetic resonance imaging) and specialty referrals, and more expensive lab tests, and even just routine screening tests like mammograms and pap smears, they weren’t doing because they couldn’t afford it.
Now (more people) have Medi-Cal, and we were happy because we could get more help to these patients, because they didn’t have to make a choice between getting a mammogram and eating that day.
The result was we maybe had the same total of patients but the intensity of care to all these patients went way up. There’s a lot of pent up demand. And now they have the ability to get the services.
I understand that the big problem is that we don’t have enough specialists willing to take Medi-Cal patients. How does that affect you?
Since most of the patients in Medi-Cal are assigned to a health plan, and the health plans are obligated to provide a comprehensive network.
The issues we have more are timeliness – how long it takes to see the contracted specialist, and location.
For example, if I make a referral to a gastroenterologist for my patient in Escondido, the contracted specialist could be in Chula Vista.
It’s not that easy for our patients to get to Chula Vista.
They may not have reliable transportation.
The public transportation system here would take them several hours on a bus if they could figure out how to even do it. And, if they have to take a day off to go to doctor, they may not be able to feed their family that week, or they might lose their job.
So, it’s not only a convenience factor. It’s a real problem if you have to go across the county to get to a specialist.
What about the delays in time for Medi-Cal patients to get appointments with specialists?
It varies by specialty. And it depends on what the seriousness of the issue we’re dealing with is. If someone has been having back pain for years, probably not as urgent as somebody who is having chest pain today.
I think some of the times I would like to see quicker or closer appointments, especially for our North County patients who need services in orthopedics and gastroenterology, rheumatology, neurology and neurosurgery.
Those are kind of the areas where our patients end up having to wait a long time because of limited specialty networks.
It’s a lot tougher for patients who have Medi-Cal but haven’t been put in a health plan yet.
There’s very few specialists of any kind who will take a straight Medi-Cal patient in North County, with exception of pediatrics.
Why are appointment wait times so important. What could go wrong?
Well, there’s a lot of reasons. One, is if there’s something bad wrong, it can get worse if it takes six months to see a specialist. It can go from not so bad to bad, or not so bad to horrible.
If someone has a fractured arm. You don’t want them waiting six weeks to see the orthopedist. And that happens sometimes. Someone who has rectal bleeding, for example, you really don’t’ want them waiting six months to have a GI evaluation.
And that is the length of wait times that you’ve been seeing?
Sometimes, yes.
What role do community clinics serve in San Diego County compared with doctors in private practice?
We’re the safety net for San Diego County. There’s no county clinic system like there is in some counties. There’s no county hospital. The safety net is essentially the community health centers providing good strong primary care.
And I like to think that we’re keeping people out of the hospital and avoiding unnecessary emergency room use and things like that. I think we can do a lot better on that stuff, but yeah, it’s the private non-profits (community clinics) in the county that are seeing all these million folks, one-third of our population that’s on Medi-Cal.
In addition to primary care, you also provide dental services, and mental health services. What else?
We’ve got pharmacists who are part of our care team now, because our patients’ medications lists are 10 or 20, 25 meds long. And sometimes if you have a 15-minute visit, it takes just that long to verify the medications and now you’re out of time to actually do the visit.