As a retired pediatrician, I feel I must comment on your article about forgiving student loans for young physicians. Being retired, I no longer have any financial stake in this issue save being a taxpayer.
There is no question that forgiving student loans is a good thing, but it’s not really going to help primary care medicine for MediCal patients nor providers.
There are at least two large problems with the current MediCal system. First, reimbursement. MediCal pays only a dozen dollars or so for a standard office visit. What’s the problem with this? When you pay your physician a dollar, he or she has to pay employees, rent, supplies, etc. and the take-home part is less than 50%. MediCal pays perhaps one-third of the cost of the visit, so caring for a MediCal patient costs far more than it pays. If the physician isn’t busy, the paltry medical payment would be better than nothing, but the Central Valley has a shortage of primary care providers.
If it costs you around $40 to see a patient, would you prefer to get paid $70 from an insured patient or $12 from MediCal?
Of course, everyone knows doctors are rich, right? Those who know me are certain I’m not starving but imagine being 30 to 35 years old before one can start earning a living, and already being saddled with $300,000 of student debt—the size of a modest mortgage, but the interest isn’t tax deductible. This is why so few graduates of American medical schools become primary care physicians. Seeing a few MediCal patients is a reasonable charitable act. However, a new physician with a 30% MediCal practice would most likely make less than the federal poverty limit.
With the Affordable Care Act, MediCal providers were paid at Medicare rates for the first few years and many primary care doctors took on MediCal patients hoping that the increase in reimbursement would continue. It did not. Currently, MediCal pays about one fifth of what Medicare reimburses, and many doctors are refusing more senior patients because they feel the payments are not enough. Because of inadequate payment to the primary care physicians from MediCal, few take such patients on. These patients go to the Emergency Department where federal law prohibits turning patients away.
The second problem is specialist coverage. If there isn’t a full complement of specialty physicians who accept MediCal, and there is not, what does the primary care doctor do when the patient needs specialty care? Send them to emergency, of course, even if the problems aren’t emergent.
The emergency department is an expensive, overcrowded and inefficient way to provide most care. Follow-up does not exist and only acute problems are addressed. No preventive care is part of the emergency model.
As part of its charitable commitment, Kaiser Permanente, where I practiced my last 15 years, covers MediCal in some counties (alas not in Stanislaus or San Joaquin). Kaiser patients on MediCal are treated the same as all other members. Within a year, these folks learn not to go to emergency unnecessarily just like all the rest of insured people in California.
If MediCal reimbursed primary care providers acceptably, and patients could be seen in offices, much money would be saved rather than paying the much higher emergency department rates.
The MediCal system needs an overhaul, not Band-Aid remedies. Better reimbursement would be a start. Other states pay Medicaid providers adequately. Why can’t California?
Steve Jacobs practiced medicine in Modesto for 35 years, and now lives in Manteca. He wrote this commentary for The Modesto Bee.