A lack of access to health care for the poor
Tulare County, a poor, semi-rural county in California's Central Valley, has a one-third of its population on Medi-Cal - California's veresion of Medicaid. This is more than any other county in the state, yet the resources to care for the Medi-Cal population are few.
Carmen Alambar, a 40-year-old who suffers from Hodgkins lymphoma and lives in Tulare County, said that if she wants her disease to be treated, she has to travel all over the state to get a doctor who takes her Medi-Cal insurance.
According to local health care professionals, Alambar is not alone in her struggles with access to care.
More than one in three people in Tulare County is enrolled in the shared state and federal government health insurance program Medi-Cal. With 35 percent of its 447,814 residents enrolled in Medi-Cal, Tulare County has more of its population in the program than any other county in the state.
While the county has plenty of Medi-Cal enrollees, those patients often have a hard time finding doctors who accept the insurance. There are already too few physicians to serve the insured population, according to local health care professionals.
They also say that low Medi-Cal reimbursement rates discourage physicians from accepting Medi-Cal patients when they can get paid more by privately insured patients.
Patients who want primary care in Tulare County must go to clinics that accept Medi-Cal. There they endure long waits that can cut into workdays, and they usually don't get to see the same physician on every visit.
They may not even see a doctor at all, as many of the clinics rely heavily on physician assistants and family nurse practitioners to treat patients.
If they must see a specialist, a trip outside Tulare County is likely in order. These trips have become a part of life for any Tulare County MediCal patient with a chronic condition.
About 200 of the county's 484 physicians accept MediCal, according to a recent investigation conducted by the Visalia Times-Delta. Some physicians may work a few hours a week at clinics that take MediCal, or they may limit the number of MediCal patients they will accept at their private offices.
Fresno County is second on the list behind Tulare County, with 30 percent of its population on MediCal. But this more densely populated county has more options for enrollees, including a teaching hospital in Fresno Community Regional Medical Center through the University of California-San Francisco, where MediCal is accepted.
Lack of access
When Alambar was diagnosed with Hodgkins Lymphoma four years ago at the age of 36, she wasn't surprised.
Close family members had suffered from various forms of cancer over the years, and Hodgkins is genetic. It affects the lymph nodes and the blood, and therefore the entire body. Alambar first knew something was wrong when her throat swelled so much she couldn't eat, and eventually couldn't breathe.
While she knew treatment for the disease would be tough, she didn't anticipate the hoops she'd have to jump through in Tulare County. She already lives in a rural part of the county, so just getting to any of the larger cities for basic treatment is difficult since she doesn't own a vehicle.
She also has to go to Bakersfield for PET scans, even though the technology for PET scans is available in Visalia, the city closest to her home. It just isn't available for her — a MediCal patient. A PET scan, or positron emission topography, uses a radioactive substance to look for disease in the body and produces a 3-D image that shows how it functions, according to the National Institutes of Health.
Alambar was initially enrolled in MediCal because she was staying home and taking care of her children while her husband worked a low-paying job, she said. Now, with the lymphoma ravaging her body, she couldn't work even if she wanted to do so.
When public transportation isn't an option for traveling to her many medical appointments, whether in Tulare County or elsewhere, Alambar has to ask family and friends for a car. She and her husband, David Zias, scrape together the money for gas. Some MediCal insurance providers will reimburse for travel, but the money for it still has to be paid up front.
Then there are the trips to San Francisco for blood tests, which Alambar said are done at a university hospital where the technology surpasses that in Tulare County. She is referred to these out-of-county areas by Tulare Community Medical Center, where her oncologist and hematologist, Dr. Kuo, works a few hours every week.
Dr. Kuo did not return our phone calls, but Maria Calderon, a referral clerk at the center, said it's true that many MediCal patients whose needs can't be met at the clinic have to travel beyond Tulare County to see a physician. Sometimes, as in the case of Alambar's San Francisco trips, it is to take advantage of superior technology.
Even someone with private insurance may have to make a trek to get the best treatment, Calderon said.
Such is not the case for other specialist services and procedures, though.
"When they sometimes have to travel to Bakersfield or Delano or somewhere else in the [Central] Valley it's because it's where the insurance authorizes it," Calderon said. "Most of the doctors here, the specialists, have their own private offices and most of them don't take MediCal whatsoever."
Graciela Soto-Perez, CEO for Tulare Community Health Center, said her clinic struggles to keep specialists on staff to meet the needs of their patients. Just this past year a gastroenterologist and an otolaryngologist left the clinic. Another much-needed specialist they don't have is a rheumatologist.
"The need for specialists is high, and they usually [don't take MediCal] because of the money. I don't blame them," she said.
A lack of doctors
The available doctors that accept MediCal can change quickly, so lists become outdated almost as soon as they are made, said Tony Cava, spokesman with the California Department of Health Care Services.
Physicians will drop out of the program, new ones join, and others are suspended, he said. No list is 100 percent accurate because of these fluctuations.
Even with a rough idea of who takes MediCal, it still isn't clear how many hours out of each week a physician accepts MediCal. Many physicians who see patients at rural clinics have their own private practices and may spend as little as one hour a week offering their services at the clinics where they accept MediCal.
For example, while Tulare County offers the services of two pediatric pulmonologists at its Tulare Pediatric Health Center location; both spend an average of one hour a week there.
It's virtually impossible to find a gastroenterologist or cardiologist in Tulare County who takes MediCal, said Mylene Rucker, a private physician in Visalia.
She said she's tried to refer some of the few MediCal patients she sees to specialists, and can't find Tulare County-area doctors who will accept them. Either the physicians aren't taking new patients at all, or they aren't accepting MediCal insurance.
"It's a problem. Nobody takes [MediCal]. Even some of the patients who are willing to travel can't find doctors who take it," Rucker said.
She stopped accepting new MediCal patients more than a year ago because of the strain on her own finances, which is the reason many private physicians don't take the low-paying insurance, she said.
A lack of efficiency
MediCal patient Nicole Phillips had to wait a year to be referred to an orthopedic surgeon to find out what was wrong with her hip after she was involved in a car accident.
"They said they were changing providers or something like that," said the 34-year-old Visalian as to the explanation she was given for the delay.
When she was finally given a referral, it was to the Adventist Medical Center in Hanford. In the meantime, the formerly-employed Phillips has begun to draw disability because she cannot work. It works against everyone for the MediCal system to be so inefficient, she said.
Jaime and T.J. Kelley know too well this inefficiency. It's come to a point where they don't attempt to get primary care because the wait is too long and the quality of care is affected by an overloaded system, they said. It's a story many patients at rural clinics and federally qualified health centers — such as Family HealthCare Network — can repeat, the Kelleys said.
"We've talked to people in the waiting room [at Family HealthCare Network in Visalia] and most of them have to take the day off of work to see a doctor. They'll lose that money from work," Jaime Kelley said.
Once they see a physician, it's never the same one. T.J. Kelley said he thinks his family, including his two young daughters, have probably seen every doctor employed at the Visalia clinic. It may seem like a small inconvenience, but the Kelleys said they would be more comfortable having one doctor who doesn't have to waste the little time they get with the physician flipping through their charts.
"Why have a primary care doctor if you can't see them?" questioned T.J. Kelley. "We don't go to the doctor anymore unless we really need to, or the kids need shots. The [doctors] want to know the basics of what's wrong, but it doesn't seem that they care much about the patients."
Wait times at Family HealthCare Network are an average of 20 minutes, said Harry Foster, executive director of Family HealthCare Network.
"What we tell the patient is, 'Do you want to see your regular doctor?' and if they say 'Yes' and that doctor is overwhelmed, we'll tell them what the estimated wait is and then we'll tell them we have other people available in the meantime," Foster said.
A lack of equality
There are facilities in Tulare County that take Medi-Cal, and there are others that take private insurance. The fact that they are separate creates inequality in health care access and services, said Foster.
"Everyone should have the appropriate level of care and access," he said. "Two-tier is when all the people with insurance and Medicare [government insurance for seniors] go to clinic A and the people who are either self-pay/no insurance or MediCal go to clinic B."
That is the approach that some private facilities take, according to Rick Strid, executive director of the Visalia Medical Clinic, the largest physician-owned clinic in the Central Valley. He said all the clinic's physicians may take MediCal when they are on call at a hospital, but none of the physicians at Visalia Medical Clinic take MediCal in their private offices.
"Basically [we don't take MediCal] because there are clinics in the area that are MediCal providers, such as Family HealthCare Network, and they're set up to take care of them. They're federally qualified and they get paid a certain amount for taking care of those patients," Strid said. "They would actually get [paid] more than we would since we're not a federally qualified health center. We don't get paid as well, but that's not the sole reason. The sole reason is there are clinics set up to take MediCal."
There are reasons besides money that some doctors refuse MediCal patients, Foster said.
"[The doctors] may not want to take people who are eligible for MediCal and have them in their offices. I've heard that before. Anyone who's impoverished and uneducated is going to be a challenging patient," he said.
Most physicians who put in a few hours a week or month at rural clinics are contracted to do so, and they get paid more if they see MediCal patients there rather than in their own practices, said Gary Herbst, CFO for Kaweah Delta Health Care District.
Some physicians who say they take MediCal may have a limit on how many of those patients they'll take every month, said Foster.
Family HealthCare clinics throughout Kings and Tulare counties have added 24 physicians in the last year, and will continue hiring at that rate as the network expands, he said. But a caveat to receiving federal funding is that Family Health Care Network cannot hire any specialists. They are limited to employing primary care physicians including obstetrics, family practice and pediatrics.
Of the physicians in Tulare County who accept MediCal, about 30 take MediCal patients at their private practices. The remainder are either affiliated with a rural clinic or federally-qualified health center, or have contracted with a hospital.
The main reason is the money, said Rucker, who will take patients who have both Medicare and MediCal, but not patients with MediCal alone.
"I used to take it but I went broke. The only way the larger organizations are taking it is because they got a grant. The county has county money. They are not the good guys, they have a back-up plan. I would take MediCal if it would pay," Rucker said.
Physicians who do accept MediCal will end up compensating for low reimbursement by seeing more patients, said Randall Morris, administrator for Imaging Associates of Porterville, which provides radiology and other services.
"I work with a lot of doctors and it's crazy because you want to take care of your patients but they tie your hands," he said. "You have to see double or triple the number of patients to get any decent amount of money, and [the patients] are suffering quality of care."