Healthcare crisis: Not enough specialists for the poor

The blurry vision began early last year. Roy Lawrence ignored it as long as he could. But after falling off a ladder at his construction job, he knew he had to see a doctor.

He went to a community health clinic in South Los Angeles, where doctors determined he had diabetes and cataracts. The clinic could manage his illness but referred him early this year to the county health system for eye surgery.

Nearly a year later, Lawrence, a Jamaican immigrant without insurance, still is waiting for the operation. His vision has deteriorated so much he is considered legally blind.

"I want to see again," he said. "I've been waiting a long time."

Lawrence, 49, and patients like him are posing a critical challenge for the planned overhaul of the nation's healthcare system. Federal officials are investing billions in community health centers like the To Help Everyone (T.H.E.) Clinic, where Lawrence's problem was diagnosed, with the hope that they can keep more patients out of high-cost emergency rooms.

But a dearth of specialists available to low-income patients presents one of the bigger hurdles facing the country as it tries to bring spiraling healthcare costs under control. Doctors say meeting new government mandates to keep patients healthy and out of hospitals — a linchpin in reducing medical spending — will be virtually impossible without the ability to make timely patient appointments with specialists.

By the end of the decade, the nation will be short more than 46,000 surgeons and specialists, a nearly tenfold increase from 2010, according to the Assn. of American Medical Colleges. Healthcare reform is expected to worsen the problem as more patients — many with complex and deferred health needs — become insured and seek specialized treatment.

Many of the newly insured will receive Medi-Cal, the government plan for the needy as administered through the state of California. Clinics already struggle to get private specialists to see Medicaid patients because of the low payments to doctors. Last week, an appellate court decision that authorized the state to move forward with 10% cuts in Medi-Cal reimbursement, which could make finding doctors for those patients even more difficult.

"Specialists are paid so poorly that they don't want to take Medi-Cal patients," said Mark Dressner, a Long Beach clinic doctor and president-elect of the California Academy of Family Physicians. "We're really disappointed and concerned what it's going to do for patient access."

The healthcare overhaul includes initiatives aimed at reducing shortages of general medicine professionals but does little to increase the availability of specialists.

In Los Angeles County, the sheer volume of poor or uninsured patients needing specialist services has long overwhelmed the public health system, creating costly inefficiencies and appointment delays that can stretch as long as a year and half.

Patients' conditions often must be dire for them to see a neurologist, cardiologist or other specialist quickly. Community clinics try to bypass the backed-up formal government referral system by pleading, cajoling and negotiating to get less critically ill patients like Lawrence moved up on waiting lists.

"Where needs are absolutely critical, we are able to work out special arrangements," said Rise Phillips, chief executive of T.H.E. Clinic. "That is not the norm. That is, rather, the exception."

At times, clinic staff members are forced to work against one of their key missions by sending patients to emergency rooms to increase the odds of their seeing a specialist more quickly.

The challenge can be seen in Belinda De Leon's cubicle in a small, windowless back corner of T.H.E. Clinic. A referral specialist, De Leon spends her days trying to speed up appointments for the center's clients — and fielding calls from patients wanting to know how much longer they have to wait. At any given time, she's juggling more than 1,000 pending referrals.

One involves uninsured housekeeper Juana Barrera. Barrera, 45, has been waiting since April 2011 to see a gastroenterologist and get a colonoscopy. She has had bleeding off and on and recently started having pain in her stomach.

On a recent visit, she told De Leon she is scared to wait any longer. But she can't afford to pay for the test out of pocket. "I'm hoping it's not anything like cancer," she said.

De Leon promised to update Barrera's referral paperwork to indicate she is experiencing pain. "Hopefully that will help," she said.

This story was originally published in the LA Times on December 15, 2012

Photo Credit: GINA FERAZZI /LA TIMES