Access to Care

Adapted from my testimony given at a legislative hearing entitled “Healthcare: Will it be there when you need it?” to California State Senate Budget Subcommittee on Health and Human Services, Senator Denise Moreno Ducheny, subcommittee chair, and Senator Tom Torlakson, subcommittee member, on March 23, 2005, at the UCSD Hillcrest Medical Center Auditorium, San Diego, California.

Many obstacles lie between patients and their access to healthcare by physicians. These obstacles fall into three broad areas: 1) physician factors, 2) health plan or insurance factors, and 3) patient factors.

Physician Factors in Access to Care

In November 2002, SDCMS published “Is There a Doctor in the House? San Diego’s Looming Physician Shortage,” the report of the SDCMS 2002 Physician Workforce Survey. That report found that the San Diego physician workforce is aging across all specialties and across all geographic regions of the county. Many practicing physicians are leaving San Diego County, retiring early, or reducing the time they spend in patient care. Medical/surgical residents and fellows who have completed their training here are not staying in San Diego, citing the high cost of living, significant medical school debt, and low reimbursement to physicians. Seventy-one percent of practicing physicians surveyed reported difficulty recruiting physicians to their practices. Thirty-five percent of survey respondents said they plan to leave the practice of medicine in the next three to five years. The top four reasons cited for physician dissatisfaction were 1) managed care, 2) government regulation, 3) low reimbursement, and 4) less time with patients.

Health Plan Factors in Access to Care

Health plan or health insurance factors include reduced reimbursements for the provision of healthcare across all payer types and the increased “hassle factor.” Getting paid for our work is frequently delayed, paid at a discount (sometimes an unauthorized discount), or not paid at all as health-insurance plans can retroactively deny payment for “pre-authorized” medical services. Often the time invested in appealing these unpaid claims for services rendered is not worth the dollars we may recover. Health plans know this and have used it to their own advantage and to the detriment of the physician’s bottom line. Dealing with unfair payment practices continues to erode the usually agreeable nature of physicians whose businesses are thus jeopardized.

Medi-Cal reimbursement for outpatient services 1) does NOT cover the cost of delivering that care, 2) is subject to the sometimes whimsical California state budgetary process, and 3) is so low that fewer than half of California physicians in private practice will see Medi-Cal patients on an elective basis.

Reimbursement to physicians for the provision of care to Medicare beneficiaries will fall 5.2% next year (2006) and will decline by a total of 31% by 2013 unless the U.S. Congress fixes the payment formula by which physicians are paid. While payments to physicians are cut, no other sector of healthcare delivery is asked to sustain these cuts. In 2006 the Center for Medicare and Medicaid Services (CMS) projects there will be increased reimbursements for the provision of care to Medicare beneficiaries in Medicare Advantage (Medicare managed care, up 4.0%), home healthcare services (up 3.3%), hospitals (up 3.2%), and nursing homes (up 2.7%). Only physicians will face sharp cuts in reimbursement unless Congress fixes the SGR (Sustainable Growth Rate) formula by which doctors are paid for evaluating and treating Medicare patients.

This sharp decline in Medicare reimbursement has the additional feature of reducing physician reimbursement for the provision of care to patients with commercial (non-Medicare) healthcare insurance where the reimbursement is indexed to Medicare rates.

The result is physicians leaving patient care, not because we want to but because reimbursement for providing medical services is falling while the cost of doing business (the medical inflation rate) is rising. Add to that the defensive medicine we must practice in a litigious society, our hospitals under growing financial pressure, the managed care “hassle factor,” and the unfunded mandates of local and state governments and the practice of medicine has lost its luster.

Patient Factors in Access to Care

Having health insurance and having a primary care physician are predictors of greater access to healthcare. Conversely, the risk factors for reduced access to quality healthcare services include the lack of healthcare coverage. While employment is no guarantee of having healthcare coverage, being unemployed makes healthcare coverage unaffordable unless one qualifies for a public assistance program. Unemployment, low income, Latino, and/or less than a high school education are all risk factors for reduced access to healthcare services.

According to “Charting the Course IV 2004: A San Diego County Health Needs Assessment” published by the Community Health Improvement Partners (CHIP) in March of this year, 81% of adults had medical insurance and 89% of parents of children under age 19 reported that their children had medical insurance in 2003. The lowest rates of medical insurance in San Diego County were reported for residents in central San Diego County (69%), Latinos (58%), households with annual incomes less than $20,000 (48%), and persons with less than a high school education (36%).

Uninsured San Diegans often do not have a primary care physician, more often use the emergency room as their usual place of care, more often do without screening exams and preventive care, delay or forgo needed medical care, and are therefore subject to more avoidable hospital stays than insured San Diegans. They are more likely to be sicker, die earlier, and die in the hospital than insured San Diegans. This is costly both in humanitarian terms as well as in dollars.

We must cover the uninsured to achieve universal access to healthcare. Please consider the CMA plan, which proposes individual mandatory catastrophic and preventive healthcare insurance.

Thank you, Senator Ducheny, for asking the San Diego County Medical Society for the physician’s perspective on access to healthcare. And thank you for your support of CMA’s efforts, which stopped the proposed cuts in Medi-Cal reimbursement to physicians in 2004.