It's difficult to find a San Diego physician willing to comment on his experience, but when doctors do talk, reactions are consistent. Providers see themselves caught in a three-way dilemma.
“I can’t afford it,” says Dr. John Beck, an orthopedic surgeon, about Medi-Cal. “The payment from the State of California is so low that I lose money seeing these people. I’m an orthopedic surgeon, and orthopedics, as a rule, requires a lot of expense on the part of the physician. For example, cast materials, braces, x-rays. I have to pay for all of that. When I’m not reimbursed for that anywhere near what I spend on it, then I’m actually paying out of my pocket to take care of these people. I’m sorry, but that is not a valid system.”
Beck, 51, lives in San Diego and has an office in Mission Valley. Recently he has stopped accepting new Medi-Cal patients and now sees only those he was previously treating.
“For an anterior cruciate ligament operation on the knee,” he explains, “[my] surgeon’s fee is normally about $3000. There’s an assistant necessary, and that’s 20 percent, $600. The last ACL I did under Medi-Cal, I believe I was paid under $600 for it. The assistant was disallowed. So out of a $3600 bill, I was paid under $600. My overhead expense level is 40 percent. Forty percent of $3000 is more than $600.”
Dr. David Kaufman is a 52-year-old psychiatrist with a practice in Rancho Bernardo. There is still a little of his native Boston in his voice. His small but comfortable office is in an office building that looks more like a Spanish villa.
Dr. Kaufman says he sees Medi-Cal patients only on occasional referrals from other physicians. “With Medi-Cal it’s really very simple,” he says. “Medi-Cal just really doesn’t pay enough money — to physicians generally, but I think it’s even worse in psychiatry — so that one would be able to pay their bills. They’re asking people who have had at least eight years of schooling and training after college to work for $39 an hour. That’s what they’re paying now, $39 per patient, which is pretty much an hour. I think my handyman makes more. For them to expect someone with eight years of training after college to work for that rate is — to me it’s insulting. So it’s just that simple.”
“Frankly speaking, if you have your door open in a specialty practice to Medi-Cal patients,” says ear, nose, and throat specialist Dr. Ted Mazer, “you would be inundated with them, and everyone you see loses money for the practice. So there is no way to make a successful practice on Medi-Cal. The reimbursement is so poor that it costs us more to perform most services than we get reimbursed.” From behind his desk in his modest College Area office that overlooks Interstate 8, 37-year-old Dr. Mazer speaks very rapidly but clearly. He has short brown hair and piercing eyes.
Flipping through his office log, he offers examples of his Medi-Cal reimbursements. “In this office we’ll see referrals frequently with kids with recurring tonsillitis, which is something simple That child comes in, we see them for an initial office visit, and generally our charges would be about $70, and we get reimbursed $46. That happens to be one of the better reimbursements we get from Medi-Cal. Here’s a tonsillectomy. Our charge was $550. To give you an idea, that includes the preoperative visit, the surgery and the postoperative care in the office. Any follow-up office visits are also included in that charge. [Medi-Cal’s] reimbursement was $161. Most payers in the open marketplace would allow any where from about $400 to $700 for that procedure. When I first started practice in ’88, we routinely got $500 to $550 for that from most payers, and we’re talking getting one quarter of that [from Medi-Cal today].”
Most affected by low reimbursements are doctors who specialize in primary care, such as family practitioners and pediatricians. Their money is made by seeing several patients through the course of the day as opposed to one or two patients for a more expensive surgical procedure. More patients mean more paperwork, staff, and office space. The fixed costs of running a practice, therefore, are higher for primary care physicians. In most cases, more than half of the charges for primary care go to paying overhead costs. This makes primary care physicians like pediatrician Dr. Stuart Cohen especially reluctant to take low-funded Medi-Cal patients.
Dr. Cohen is tall and dark complexioned, with bushy black hair and mustache. His nicely decorated offices are in the College Area. He says he does not see any Medi-Cal patients except those he’s already treated whose families have hit bad luck or lost jobs and had to depend on Medi-Cal coverage, or follow-up care for patients he has first treated in a hospital.
“What’s happened is that state budgets and other cutbacks have limited the reimbursement rates on Medi-Cal to the point where the average payment for a pediatric visit basically doesn’t even meet our costs. A standard office visit is $50. Private insurance reimbursements range from $32 up to a full $50. Medi-Cal pays $14. If we counted overhead expenses — nurses, a nice office here with a lot of medical information systems, we can’t make a living off of it.”
One local ophthalmologist, we’ll call him Dr. Z, also limits his Medi-Cal practice to referrals and existing patients. He says “Well, in ophthalmology, the standard, complete eye examination is about $100. I don’t even know [what Medi-Cal pays], because whenever I’ve looked at it, it’s just depressing, so I don’t. I think it’s maybe $40 or something like that. Or cataract surgery. The charge is $3000. Medi-Cal pays about $900 to $950. So they are paying about a third of what charges are.”
Most of the doctors interviewed find their Medi-Cal patients, as a group, harder to treat. They are more likely to fail to keep appointments, which, the doctors admit, might be a transportation problem; but the doctors also observe that they rarely call to cancel, Also, some doctors say that Medi-Cal patients don’t follow treatment plans for one reason or another. One family practitioner, Dr. Gary McFeeters, cites the difficulty of seeing Medi-Cal patients as the main reason he won’t see most of them.