Should we require providers to accept Medicaid?

California’s Public Hospitals Face New Medi-Cal Mandate

By Pauline Bartolone
California Healthline, August 4, 2016

Public hospitals in California will be required to contract with at least one Medi-Cal managed care plan starting in 2018.

But advocates for low-income Californians say one regional contract with a Medi-Cal insurer is not enough to ensure adequate access to care. In addition, public hospitals may be exempted from the mandate if “good faith” contract negotiation efforts have failed.

The Western Center on Law and Poverty, an advocacy group, lobbied lawmakers to require that public hospitals contract with all Medi-Cal managed care plans in their region.

But such a mandate was not included in the hospital financing arrangement, which is part of what’s known as the “Medi-Cal 2020 waiver” — a $6.2 billion agreement between state officials and the federal government to facilitate programs related to health care quality, access and cost.

The agreement is intended to improve the quality of care and enhance access to it for the state’s 13 million-plus Medi-Cal enrollees, about 80 percent of whom are in managed care plans.

The Western Center said it decided to advocate for broader Medi-Cal coverage after hearing about the challenges Medi-Cal enrollees face trying to get specialized care at some University of California health systems.

Public hospitals like San Francisco General Hospital and Harbor-UCLA Medical Center often serve Medi-Cal enrollees, but they are not obligated to provide all services to these patients. The hospitals say that Medi-Cal managed care reimbursements often do not cover the costs they incur caring for those patients.

“We hear from our local legal aid partners that there are significant specialty access problems for some Medi-Cal members who would like to be able to access services at UC hospitals,” the Western Center’s director of public advocacy, Elizabeth Landsberg, wrote in a letter to lawmakers.

Landsberg’s group wants the new requirement for Medi-Cal contracting to provide for the full scope of health care services, including primary and specialty care.

California Senate Health Committee Chairman Ed Hernandez (D-West Covina) authored one of the bills that formally turned the new public hospital funding rules into state law. He says the Western Center’s suggested contracting requirements weren’t included because of the financial difficulty they would impose.

“Ideally, I would love to see all the public hospitals, including the UCs, see any and every Medi-Cal patient that comes in the door,” said Hernandez.

“The dilemma is…you can’t force people to see Medi-Cal patients because of the poor reimbursement rates.”


Obamacare Expansion A Bumpy Ride For Rural Health Clinics

By Pauline Bartolone
Kaiser Health News, August 3, 2016

When Medi-Cal, California’s version of Medicaid, was first expanded under the Affordable Care Act in early 2014, the number of people insured under the program doubled to around 40,000 people in the region served by Shasta Community Health. Not only did the clinics see new patients, but the demand for services soared from existing ones who were newly insured.

The clinic network already had a shortage of doctors and nurses. — a problem shared by many other rural health clinics in California.

“The … more new patients we brought in, the more stress on the providers, the more likely [they] were going to leave, the deeper the crisis went,” said Shasta Community Health Center CEO C. Dean Germano. So he decided to close the network’s five clinics to new adult Medi-Cal patients, though they continued to serve all of their existing patients and accepted new children.

Q: Were you able to meet the demand for all these new services?

Germano: No, not at all. We quickly became overwhelmed, although there were a couple of things happening all at once. One was certainly the growth in Medicaid coverage, but at the very same time, the state of California expanded Medi-Cal managed care into 28 rural counties. We are one of them. We did not have Medi-Cal managed care prior to this.

We were assigned patients, then assigned more patients. We quickly reached a point where we could not take on more new adult patients to our practice. We had to essentially constrain and at one point close the practice to new adult Medicaid patients.

It was a very big hit [to] the community because adult patients had to go further afield to find services outside of the emergency room. Under managed care, it’s [the health plan’s] responsibility to find a medical home and some of the medical homes were 30 to 40 miles into the mountains.


Medi-Cal Managed Care: An Overview and Key Issues

By Margaret Tatar, Julia Paradise, and Rachel Garfield
Kaiser Family Foundation, March 2, 2016

Access to care

Problem with access to care in Medi-Cal FFS carry over into managed care, challenging Medi-Cal health plans to establish adequate provider networks and improve care. Gaps in access to certain specialists, including psychiatrists and other behavioral health providers, and long-term care services, are the most significant gaps. Providers have cited Medi-Cal’s low payment rates as a barrier to their participation in the program and sued the state on the basis that the fees violate federal Medicaid payment standards. Language and cultural gaps in access to care and gaps in rural access are additional issues.

Major current issues

Two recent developments – CMS’ proposed modernization of the Medicaid managed care regulations and the approval of “Medi-Cal 2020,” the renewal of California’s section 1115 waiver – can be expected to bear on the Medi-Cal managed care program, by increasing plan- and state-level requirements and state oversight responsibilities, and by setting the stage for potential changes in the role and operation of managed care plans in a transforming health care delivery and payment system.



By Don McCanne, M.D.

One of the great successes of the Affordable Care Act is the expansion of Medicaid coverage for low-income individuals. But how do you define success? Let’s look at California.

One-third of Californians are on Medi-Cal - California’s Medicaid program. Yes, one-third! Yet California has one of the lowest Medicaid provider payment rates in the nation and frequently does not cover the costs of care provided. California has now transferred about four-fifths of the Medi-Cal patients into managed care. Managed care plans have significant additional administrative costs, yet payment rates were not increased over what was being paid under the fee-for-service program. That means that the actual health care providers have had a further net decrease in payment rates.

So who is going to see these patients? Do you send them to local community health centers? These centers have had problems recruiting enough primary care professionals and thus have had difficulties accepting more Medi-Cal patients. The Shasta Community Health Center even had to temporarily close the practice to new adult Medi-Cal patients. Where do they go?

Taxpayer-supported public hospitals and clinics, including the University of California health systems, seem like a logical place to refer these patients. But they have the same capacity issues. Further, many specialists in the community refuse to accept Medi-Cal patients and thus a greater burden would be placed on the academic center specialists. Most of these specialists are not advocates of noblesse oblige. They particularly do not want to be overworked and underpaid.

Just as emergency departments no longer have the right to refuse patients, some suggest that physicians, hospitals and clinics also be required to accept Medi-Cal patients. Although this was considered, the California legislature decided to take a lesser step. As of 2018, all public hospitals in California will be required to contract with at least one Medi-Cal managed care plan.

This may not seem like that big of a deal, but it does expand the principle beyond emergency departments that the government can mandate that providers be required to see patients while refusing to adequately fund their care. Will it be private hospitals next? Outpatient centers? Private medical practices? Real problem, wrong solution.

What we need instead is an equitable system of financing health care - a single payer national health program. A patient’s access to care should not depend on the payment source, as it does now. Access should be based strictly on health care needs, backed up by an automatic, equitable payment system.