Delay in Pilot Medi-Cal Plan Is Foreseen by Physicians

SAN DIEGO —  An official of the Los Angeles County Medical Assn. predicted Thursday that the state’s Medi-Cal pilot project, scheduled to begin in the San Fernando Valley in January, will be postponed because there won’t be enough doctors to treat the poor and disabled.

Bob Holt, hospital relations officer for the association of physicians, made the prediction during a hearing by the Assembly Health Committee to solicit opinions from physicians, health maintenance organizations and health advocacy groups on the feasibility of the Expanded Choice Program.

Holt said an analysis this week of data gathered by his organization, and interviews with Valley physicians, suggest that proceeding with the program “will significantly reduce the number of physicians treating Medi-Cal patients.”

Michael W. Murray, executive director of the California Medical Assistance Commission, the agency in charge of the experiment, said he will not know until next month whether there will be enough physicians in the program for it to be implemented on time.

73 Full-Time Physicians Needed

But program officials apparently should have little trouble signing up the minimum number of physicians required under a state formula. The Medi-Cal experiment is mandated to have at least one physician for every 1,200 Medi-Cal beneficiaries, according to Jim Foley, the state official overseeing the Valley experiment.

With 87,000 Medi-Cal patients in the Valley, the program would need the equivalent of 73 physicians working full time to meet the requirement. However, few physicians are expected to devote their entire practice to Medi-Cal patients, so the minimum number required would have to be higher.

Also, those physicians must be spread throughout the area so that they can be easily reached by patients eligible for Medi-Cal, the state medical care program for the poor and disabled.

Holt did not predict the number of physicians who would participate. He argued, however, that the pool of physicians available to treat Medi-Cal patients would be inadequate because the experiment will exclude almost all of the about 950 Valley physicians who now accept Medi-Cal patients. There are about 3,800 physicians in the Valley.

State officials say they hope the program will increase taxpayer confidence in the much-maligned multibillion-dollar Medi-Cal system and will be successful enough to be implemented statewide.

The state experiment is scheduled to start in the Valley and San Diego County in January with enrollment of Medi-Cal recipients in participating HMOs. Patient care under the program is to begin April 1.

State officials say they hope the program will increase taxpayer confidence in the much-maligned multibillion dollar Medi-Cal system and will be successful enough to be implemented statewide.

The program has been criticized by patient advocates and medical societies, which contend that the experiment will sever patient-physician relationships and possibly lower the quality of care.

In an interview after his presentation to the committee, Holt said there will not be enough doctors in the experiment because eight of the nine HMOs that have applied for inclusion in the program in the Valley will be using few, if any, of the outside doctors now treating Medi-Cal patients.

Kaiser Permanente, for instance, is a “closed” HMO that uses only doctors on its payroll. HMOs that are “open” subcontract with private physicians, who treat HMO patients under fees set by the HMO.

Subcontracting Encouraged

The California Medical Assistance Commission is encouraging the nine HMOs to subcontract with as many of the physicians now treating Medi-Cal patients as possible, Murray said. The more private physicians involved in the program, the less disruption there will be for patients because more of them will be able to continue seeing their own physicians, he said.

State officials will not know how amenable HMOs have been to their wishes until they review the HMOs’ applications. But, according to Holt, the only HMO encouraging private physicians to sign up is one being formed by Los Angeles County at Olive View Medical Center, which is operated by the county. And in that HMO, the county’s conditions for participation are so restrictive that few, if any, physicians will sign up, he said.

Holt said the county is requiring physicians to post $25,000 performance bonds, include the county in their malpractice insurance coverage and sign contracts that would release the county from any blame should problems occur.

“I think it will probably go ahead,” Holt said of Expanded Choice, “but I don’t think it will go ahead on schedule. There are too many unanswered questions.”

‘Scrambling to Sign Up’

Murray, however, said he is skeptical about the assertions of the medical association because it is opposing the experiment. “While the medical society says doctors won’t sign up, we have plans saying doctors are scrambling to sign up,” he said.

But Murray said the agency is striving to include in the program “every doctor who treats Medi-Cal patients now.”

Murray is to decide in early November whether Expanded Choice should go forward as scheduled. He will make his recommendation to the seven-man California Medical Assistance Commission, which will then hold hearings on the question. The commission will make its decision in December.

Others who spoke at the three-hour hearing--attended by Chairman Curtis R. Tucker (D-Inglewood), Nolan Frizzelle (R-Fountain Valley) and Gil Ferguson (R-Newport Beach)--included Herman Weil, assistant health plan manager of Kaiser Permanente. He warned that proposed fees will be insufficient to provide the standard of care now offered to enrollees.

Kaiser Might Drop Out

Weil said that Kaiser, considered by many to be the premiere HMO in California, would not be able to guarantee continued participation in the program if rates prove inadequate.

Another concern raised at the hearing was whether there will be sufficient safeguards to ensure that beneficiaries will not be shortchanged by HMOs trying to protect their profit margins.

Rosemary Bishop, an attorney with the San Diego Legal Aid Society, said an ombudsman program needs to be established to protect the interests of patients. She cited national studies indicating that patient care has suffered under some health care programs that charge set monthly rates for patients no matter what services they use.

Murray said that advisory committees composed of beneficiaries and health providers will be established to review complaints, and that an ombudsman program might be created later if it is needed.

Murray and HMO representatives at the hearing contended that, contrary to Bishop’s assertion, research shows that HMOs provide treatment as good or better than that provided by private physicians.