Melissa Feemster of Turlock knows the frustration of not having private health insurance.
She awoke one morning unable to move. A herniated disc in her lower back was pressing on a nerve, causing her severe pain and the loss of feeling in her right leg and buttocks.
The single mother became incontinent and was unable to continue working as a waitress at the Elegant Bull in Delhi and a Perko's in Turlock.
Feemster needed to work to feed her three children, and her Medi-Cal card wasn't much help in getting an appointment with back specialists in the area, she said.
A physician's assistant at Delhi Medical Clinic referred her to a specialty clinic at the Stanislaus County Health Services Agency in Modesto.
"The doctor's first words to me was that he donated his time to the county," said Feemster, who felt the consultation went downhill from there. "I feel for women who have jobs that don't give them insurance. He made me feel like I was a nobody because I had Medi-Cal."
According to Feemster, the specialist said even if he could help her, getting authorization from Medi-Cal to perform surgery would take six to eight weeks.
Feemster left the clinic not knowing if or when she would get the authorization and continued to take pills for the pain.
Back at the Delhi clinic, her family practitioner got her in to see a surgeon at the University of California at San Francisco Medical Center, a hospital designed to deal with more complex cases.
"I was in surgery within a week," said Feemster, who now has an office job. She since has married and has insurance from her husband's employer.
The lack of specialists willing to take Medi-Cal patients has been a pet peeve of her physician's assistant, William Dennis-Leigh. Before he retired this fall, the Delhi Medical Clinic administrator told numerous stories of low-income patients who endured pain for months while trying to find specialists to treat them.
Other nonprofit clinics have sent patients to Fresno or Sacramento just to have their tonsils removed.
A matter of money, paperwork
Even insured patients can have a difficult time in the Northern San Joaquin Valley, with its slim roster of specialty physicians.
Stanislaus County has 48 specialists per 100,000 residents, compared with 113 per 100,000 in Santa Clara County, 230 per 100,000 in Marin County and 252 per 100,000 in San Francisco, according to the Central Valley Health Policy Institute at California State University, Fresno.
San Joaquin County has 44 specialists per 100,000 and Merced County, at 21 per 100,000, has one of the lowest rates in the state.
Because of low reimbursements and paperwork hassles, an increasing number of specialists across the country are not accepting patients with Medi-caid, the nation's health coverage for the poor. (Medicaid is called Medi-Cal in California.) The Center for Studying Health System Change, a nonprofit research group, reported in 2006 that nearly half the nation's physicians were not taking Medi-caid patients or restricted how many they accepted.
In a California survey, 85 percent of medical directors at community health centers said their patients frequently had trouble getting access to specialists, according to the California Healthcare Foundation. The clinics had the most trouble referring patients to neurologists, immunologists and orthopedists.
A random survey of 10 specialty practices in Stanislaus County last month found that seven did not accept Medi-Cal, two accepted Medi-Cal but restricted the number of patients, and one said it accepted Medi-Cal referrals.
One of the few options in Stanislaus County are the Health Services Agency specialty clinics at the Scenic Drive complex in Modesto, which serve about 20,000 patients a year, including people with Medi-Cal and Medicare, uninsured patients and some with private insurance.
Elizabeth Cooper manages the specialty clinics. She said her biggest challenge is finding specialists to serve in the clinics. The agency has a full-time oncologist and semi-retired general surgeon, and pays hourly rates to specialists in the community to come in a few days a month.
None of the doctors donate their time, Cooper said, adding that the specialist who saw Feemster might have been joking about his pay.
"They have full-time practices with huge overheads to meet," Cooper said. "But they give us what time they have. It is difficult to see as many patients in a timely manner."
Majority are referrals
Most of the patients are referred by primary care doctors in the Health Services Agency, community health clinics and officials in hospital emergency rooms.
Cooper said the clinics sometimes deny referrals if a specialist has quit and the waiting time for patients is more than four months. The clinics often deal with the Medi-Cal system, so there are delays in getting procedures approved for patients. An authorization for a surgery or even a CT scan can take six to 12 weeks, she said.
She added that Medi-Cal is coming out with a system to expedite authorizations.
The Health Services Agency says it isn't obligated to provide specialty care -- or any kind of medical care -- for the large Medi-Cal population in Stanislaus County. The state does require the county to provide care for medically indigent adults, who don't qualify for Medi-Cal.
As the agency tries to reduce annual deficits of $8 million to $16 million, there are no proposals to eliminate the speciality clinics, but the county would like private physicians to take more of the Medi-Cal patients.
"It is not the county's responsibility to see everyone," said Phoebe Leung, an HSA spokeswoman.
Beside the cancer clinic and general surgery, the county's specialty clinics include orthopedics; urology; ear, nose and throat; podiatry; gastroenterol-ogy; neurology; neurosurgery; and colon examinations. The clinics also care for people suffering from the long-term effects of the AIDS virus and hepatitis C infection.
Waiting too long
The busiest clinics are orthopedics and oncology. Chemotherapy is provided in the former county hospital on Scenic Drive, which closed in 1997.
Dr. R. Michael Williams, the oncologist and medical director of the specialty clinics, can cite countless examples of patients coming in with advanced forms of cancer that weren't caught earlier because the patients weren't seeing a doctor regularly.
Some women have masses in their breasts but didn't come in sooner because they lacked insurance. One man was seriously ill from a blood disorder and waited to be seen until the grape harvest finished.
Although the specialty clinics mostly have been spared the budget ax, a decision last month to eliminate clinical laboratory services creates "enormous" difficulties for treating cancer patients, Williams said. They need a blood analysis the day before chemotherapy and now will have to go to outside labs.
Many patients don't have transportation, and there's concern outside labs won't provide the results in time.
"There will be situations where we will have to delay the treatments," Williams said.
Dr. Alan Yates, an ear, nose and throat specialist in Modesto, devoted six half-days a month to the county clinics and saw 30 to 40 patients each time until the HSA canceled contracts with two of the three ear, nose and throat physicians in 2005.
"Where the patients have been going, I couldn't tell you, but we are seeing a number in the emergency room," Yates said.
Yates said most private practices, including his own, do not accept Medicaid because the reimbursements in California are among the lowest in the nation, while overhead costs are high. He treats Medi-Cal patients when he's on call in the Doctors Medical Center emergency room and then sees them in his office until their acute condition is resolved, he said.
Tim Noakes, chief executive officer of Stanislaus Surgical Hospital in Modesto, said that when Medi-Cal covers a surgery at the hospital, the reimbursements don't meet the costs of nursing care and supplies. Medi-Cal patients make up 2 to 3 percent of the hospital's outpatient cases; its 23-bed inpatient wing isn't contracted with the program.
Noakes said the large uninsured population in the Central Valley is one reason specialists decide against practicing in the region.
"We are seeing more specialists leave the community than come to the community," he said. "They are leaving for better opportunities."
Insurance no guarantee
Other safety net centers such as Delhi Medical Clinic and Golden Valley Health Centers mainly provide primary care, administrators said.
Michael Sullivan, executive director of Golden Valley, said recent legislative proposals to expand coverage for the uninsured in California have not addressed the shortage of specialists.
"Our state lawmakers seem to think as long as you give everyone an insurance card that access to care will be available to all, and that is a fallacy," he said. "If you don't have doctors who want to accept that kind of insurance, the care is not going to be given."
Golden Valley is doing more to offer specialty care. Psychiatric counseling is available in its clinics in Merced and Stanislaus counties; an ear, nose and throat specialist will start seeing patients in January at the Florida Avenue clinic in Modesto; and there are plans for optometry service.
Bee staff writer Ken Carlson can be reached at firstname.lastname@example.org or 578-2321.