Refer to: Jones MW, Hamburger B: Survey of physician participation in and dissatisfaction with the Medi-Cal program (Socioeconomic Report of Bureau of Research and Planning, California Medical Association). West J Med 124: 75-83, Jan 1976
Information
Survey of Physician Participation in and Dissatisfaction with the Medi-Cal Program A
MICHAEL W. JONES, MBA, and BETTE HAMBURGER, BA, San Francisco A Socioeconomic Report of the Bureau of Research and Planning California Medical Association
IN LATE 1974, the California Medical Association's Bureau of Research and Planning sent questionnaires about participation in Medi-Cal (California's Medicaid program) to a random sample of 1,200 members in private medical practice. Questions covered degree of current participation in the program; plans for future participation; patterns of acceptance of new Medi-Cal patients, referrals and consultations, and similar questions about personal involvement in the program. Responses were received from almost 70 percent of physicians sampled. Subsequently, respondents who have curtailed participation in Medi-Cal or plan to do so were sent a follow-up questionnaire to elicit information about their perception of various problem areas within the program. From these data, evaluations can be made concerning the types of reform that might be most fruitful in eliciting the broadscale physician participation on which the program is conceptually based. Well over threequarters of the 336 physicians in this subsample group provided data. These findings represent highlights of a detailed report, single copies of which are available on request from the CMA's Division of Research and Socioeconomics. Mr. Jones is Director of the Division of Research and Socioeconomics, California Medical Association. Ms. Hamburger is a Research Assistant and Staff Coordinator. Reprint requests to Bureau of Research and Planning, California Medical Association, 731 Market Street, San Francisco, California 94103.
Part I-The Broad-Scale Sample Most Physicians Participate in Medi-Cal Program As seen in Table 1, approximately one patient in ten (9.7 percent) being treated by the average physician is covered under the Medi-Cal program. However, the table clearly shows that a substantial number of physicians (14.9 percent) practice in a situation where over a quarter of all their patients are under Medi-Cal, while a relatively small proportion (6.3 percent) treat no Medi-Cal patients whatever. More than a fourth of all respondents (25.6 percent) conduct practices in which fewer than 5 percent of their patients are on Medi-Cal. Understandably, participation differs according to medical specialty. Pediatricians tend to have a relatively higher proportion of Medi-Cal patients than do most other physicians, while internists, obstetrician/gynecologists and orthopedists have below-average proportions. Many pediatricians, general practitioners and psychiatrists have a patient load of which more than a fourth is made up of Medi-Cal patients. At the other end of the spectrum, above average proportions of obstetrician/gynecologists and psychiatrists treat no Medi-Cal patients whatever. One psychiatrist, who formerly treated Medi-Cal patients, commented that he would participate "only if Medi-Cal patients would be permitted as many visits as were necessary to help them." THE WESTERN JOURNAL OF MEDICINE
75
MEDI-CAL SURVEY
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Few Respondents Want More Medi-Cal Patients Table 2 provides information about patterns of acceptance of new Medi-Cal patients, according to medical specialty. Data from anesthesiologists, radiologists and pathologists have been excluded, since they are generally unable to make an independent decision about whom they treat. Also excluded are data from respondents who have never treated Medi-Cal patients. Among other respondents, 43.1 percent probably would accept a new Medi-Cal patient, 19.9 percent might accept one, 24.6 percent probably would not accept one and 12.4 percent definitely would not accept a new Medi-Cal patient. Thus, it is clear that only a minority of California's private practitioners would willingly provide care to a new Medi-Cal patient seeking their services if the circumstances were such that they could make such a choice. Data about physician willingness to accept new Medi-Cal patients according to their current level of participation are also shown in Table 2. Excluded from this portion of the table are respondents who indicated that they have never treated patients under the program; included, however, are anesthesiologists, radiologists and pathologists. The data show a close association between degree of current Medi-Cal involvement and willingness to continue treating patients under the program. Among physicians whose case load is currently over a quarter Medi-Cal patients, almost four out of five respondents (79.8 percent) indicated that they probably would accept a new Medi-Cal patient who requested care, while just over 10 percent indicated that they either probably or definitely would not accept a new MediCal patient seeking services at this time. At the low end of the spectrum of current Medi-Cal participation, more than six out of ten respondents (63.4 percent) indicated that they probably would not or definitely would not accept a new Medi-Cal patient, while fewer than a fourth (22.8 percent) said that they probably would accept one. This close association suggests that the base of Medi-Cal participation by California
MEDI-CAL SURVEY TABLE 2.-Acceptance of New Medi-Cal Patients, by Medical Specialty and Level of Current Involvement in the Program
Specialty/Lev el of
Current Participation
Total Respondents Number Percent
Probably Would Number Percent
Acceptance of New Medi-Cal Patients Probably Not Might Percent Number Number Percent
General/Family Practice .... 155 ........ 121 Internal Medicine1 .. Pediatrics' . ................ 41 Other Medical2 .31 General Surgery3. .......... 57 Other Surgery4. ............ 32 57 ..... Obstetrics/Gynecology Ophthalmology ....... ..... 37 Orthopedic Surgery ........ 33 Otolaryngology ....... ..... 19 Psychiatry1 ................ 54 All Other ................ 26 Total (excluding Anesthesiology, Radiology and Pathology)5 663 24 Formerly treated, none now Under 5 percent ...... ..... 189 S to 10 percent ....... ..... 156 11 to 15 percent ...... ..... 127 16 to 25 percent ...... ..... 109 Over 25 percent ...... ..... 109
100 100 100 100 100 100 100 100 100 100 100 100
52 30 23 18 32 18 24 28 10 13 24 14
33.5 24.8 56.1 58.1 56.1 56.3 42.1 75.7 30.3 68.4 44.4 53.8
32 23 11 3 11 7 13 3 6 6 13 4
20.6 19.0 26.8 9.7 19.3 21.9 22.8 8.1 18.2 31.6 24.1 15.4
100 100 100 100 100 100 100
286
69 87
43.1 4.2 22.8 42.3 48.8 63.3 79.8
132 1 34 35 33 20 11
19.9 4.2 18.0 22.4 26.0 18.3 10.1
Totals...................... 714
100
328
45.9
134
18.8
1 43 66 62
37
23.9 42.1 12.2 25.8 17.5 18.8 28.1 10.8 33.3
Definitely Not Number Percent
21.9 14.1 4.9 6.5 7.0
18.5 19.2
34 17 2 2 4 1 4 2 6 0 7 3
163 9 77 35 22 15 7
24.6 37.5 44.9 22.4 17.3 13.8 6.4
82 13 35 20 10 5 4
12.4 54.2 18.5 12.8 7.9 4.6 3.7
165
23.1
87
12.2
51 5 8 10 6 16 4 11 0 10 5
3.1 7.0
5.4 18.2
13.0 11.5
6Excludes physicians who have never treated any Medi-Cal patients.
14See footnotes to Table 1. 5Excludes 23 respondents who have never treated Medi-Cal patients, and 8 who did not respond to this specific question.
TABLE 3.-Physicians' Continued Treatment of Current Medi-Cal Patients During the Coming Year by Medical Specialty and Level of Current Involvement in the Program
Specialty/Level of
Current Participation
Total Respondents Number Percent
General/Family Practice .... 154 Internal Medicine1 . ........ 119 Pediatrics'. ................ 41 Other Medical2. ............ General Surgery .55.......... Other Surgery4. ............ ..... Obstetrics/Gynecology
Ophthalmology ....... ..... Orthopedic Surgery ........ Otolaryngology ....... ..... Psychiatry' ...............
29 S 30 52 36 31 19 49 26
All Other ................ Total (excluding Anesthesiology, Radiology and Pathology)5 . 641 Under 5 percent ........... 190 5 to 10 percent ........... 156 11 to 15 percent ........... 126 16 to 25 percent ........... 109 Over 25 percent ........... 110 Total6 .691
Continue, Plus Family Members Number Percent
Treatment of Current Medi-Cal Patients Gradually Lower Continue Number of Patients Patients Only Number Percent Number Percent
Number Percent
22 21 2 4 9 7 11 3 9 1 13 7
14.3 17.6 4.9 13.8 16.4 23.3 21.1 8.3 29.0 5.3 26.5 26.9
7 11 1 1 4 3 4 1 2 0 3 4
7.3 10.0 7.7 2.8 6.5
4
17.5 34.5 14.6 27.6 18.2 10.0 23.1 8.3 32.3 .. 14.3 15.4
61.5 78.2
131 61 27 26 12 9
20.4 32.1 17.3 20.6 11.0 8.2
109 27 30 21 25 13
17.0 14.2 19.2 16.7 22.9 11.8
41 26 7 5 5 2
6.4 13.7 4.5 4.0 4.6 1.8
57.2
135
19.5
116
16.8
45
6.5
100 100 100 100 100 100 100 100 100 100 100 100
98 46 32 16 32 17 25 29 10 18 26 11
63.6 38.7 78.0 55.2 58.2 56.7 48.1 80.6 32.3 94.7
53.1
27 41 6 8 10 3 12 3 10 0 7
42.3
100 100 100 100 100 100
360 76 92 74 67 86
56.2 40.0 59.0
100
395
2-4See footnotes to Table 1. 5Excludes 23 respondents who have never treated Medi-Cal patients, 24 who have no current Medi-Cal patients, and 7 who did not respond to this specific question.
Curtail Number of Patients Soon
58.7
zExcludes physicians
with no Medi-Cal
4.5 9.2
2.4 3.4
6.1
15.4
patients currently
their care.
THE WESTERN JOURNAL OF MEDICINE
77
under
MEDI-CAL SURVEY TABLE 4.-Medi-Cal Patient Load Expected in Three Years, by Current Level of Program Participation Total Respondents Number Percent
Proportion of Patients Under Medi-Cal
Under 5 percent ..... 5 to 10 percent ...... 11 to 15 percent ..... 16 to 25 percent ..... Over 25 percent ......
Proportion of Medi-Cal Patients in Three Years Larger
Same
Number Percent
Number Percent
Smaller
Nutmber Percent
No Answer Nuimber Percent
191 158 129 109 I 11.....
100 100 100 100 100
14 18 24 33 40
7.3 11.4 18.6 30.3 36.0
99 97 66 57 46
51.8 61.4 51.2 52.3 41.4
72 42 36 19 23
37.7 26.6 27.9 17.4 20.7
6 1 3 0 2
3.1 0.6 2.3
Total' ..................... 698 No Medi-Cal Patients Currently Under Care .... 47
100
129
18.5
365
52.3
195
27.5
12
1.7
100
3
6.4
44
93.6
0
0.0
0
0.0
.....
..... ..... .....
1.8
'Excludes physicians with no Medi-Cal patients currently under their care.
physicians is gradually narrowing and that, absent program changes, the future will find fewer physicians treating more patients under the program. Many Plan to Curtail Medi-Cal Involvement Table 3 provides information about the future plans of physicians who are currently treating Medi-Cal patients. Most physicians indicated that they will continue treating Medi-Cal patients, as well as family members. However, a substantial proportion (17.0 percent) intend gradually to lower the number of Medi-Cal patients under their care, while some others (6.4 percent) plan to curtail caring for Medi-Cal patients as rapidly as feasible. Internists and orthopedists showed particular reluctance to offer services to "family members" not currently under their care. "Other" surgeons, such as neurosurgeons and urologists, obstetrician/gynecologists, orthopedists and psychiatrists seem especially anxious to lower the proportion of Medi-Cal patients under their care. This proposed course of action was noted by very few pediatricians, ophthalmologists or otolaryngologists. Information about future plans regarding MediCal participation according to level of current involvement by physician respondents is also contained in Table 3. Most physicians with significant current involvement expect to remain involved, while those with a low level of participation plan to limit their participation even more or, in fact, curtail it entirely. The data again show that the base of physicians available to provide care under the program is narrowing and that relatively more care will be provided in the future by those physicians who already have significant involvement in the program. 78
JANUARY 1976 * 124 * 1
Further Evidence of Narrowing Base As seen in Table 4, most respondents (52.3 percent) indicated that they expect the proportion of Medi-Cal patients under their care in three years to be similar to the current proportion. Among others, 27.5 percent plan to be treating a smaller proportion. Since it is unlikely that many respondents expect the program itself to contract, one can assume that this group of respondents propose to achieve a diminished proportion by reason of their own voluntary actions with respect to participation in the program. While only 7.3 percent of physicians whose current case load is under 5 percent Medi-Cal expect to increase this proportion, almost two in five (37.7 percent) plan to reduce it. Conversely, among those physicians whose current complement of patients is over a fourth Medi-Cal, well over a third (36.0 percent) expect to be treating an even larger proportion in the future, while only one in five (20.7 percent) expect the proportion to diminish. Although the association between these two variables is extremely close, it should also be noted that a small but nonetheless significant proportion of physicians who are heavily involved in the program apparently wish to curtail their degree of involvement. The data also suggest that an almost negligible proportion of physicians not currently treating any Medi-Cal patients expect to begin participating in the program in the future. Although not shown in Table 4, among physicians who expect to be treating relatively more Medi-Cal patients, an overwhelming majority indicated that this is based on their own feeling of responsibility. Many also anticipate that more Medi-Cal patients will be seeking a new physician in the future. Relatively few physicians considered
MEDI-CAL SURVEY TABLE 5.-Respondent Ratings of Various Potential Problem Areas in the Medi-Cal Program Total
Problem Area
Responding' Number Percent
Inability to deteFmine amount Mb will be paid ........ 243 Excessive paperwork ....... 249 Delays in payment .......... 243 Difficulty in securing prior authorization ...... ..... 230 Inadequate level of reimbursement ........... 244 Denial of reimbursement for services provided . 231 Bureaucratic interference with patient care .242
Critical Number Percent
Seriousness of Problem Minor Major Number Percent Number Percent
Not a Problem Number Percent
100 100 100
57 92 73
23.5 36.9 30.0
109 101 83
44.9 40.6 34.2
62 52 66
25.5 20.9 27.2
15 4 21
6.2
100
43
18.7
83
36.1
70
30.4
34
14.8
100
125
51.2
90
36.9
26
10.7
3
1.2
100
107
46.3
81
35.1
27
11.7
16
6.9
40
16.5
25
10.3
1.6 8.6
I
100
111
45.9
66
27.3
'Excludes physicians who indicated "don't know" or who did not respond to specific portions of the question.
the program "reasonably easy to work with," while an almost negligible proportion indicated a preference for Medi-Cal patients to other types of patients. Almost half of these respondents expected that they would be treating a larger proportion of Medi-Cal patients because other physicians in their geographic area are limiting their Medi-Cal practice.
Part Il-The Follow-Up Who Provided the Data Information contained in the follow-up survey is based on responses from a sample of 336 California Medical Association members who, in answer to Part I of the "Medi-Cal Participation Survey," indicated that they either treat no patients under the Medi-Cal program or had cut back on their participation or planned to do so in the future. This represents 45 percent of the total group of physicians who responded to the earlier questionnaire. Usable responses were received from 258 of the 336 physicians sampled, or 76.8 percent. This high rate of response assures that the data represent with reasonable accuracy the opinions of physicians sufficiently alienated by Medi-Cal to have taken action with respect to their own personal participation in the program. Medi-Cal Problem Areas Identified Table 5 indicates how respondents rated various potential problem areas within the MediCal program. Over half of all respondents (51.2 percent) consider inadequate level of reimbursement a critical problem to them with reference to participation in the Medi-Cal program. Almost
as important are the problems of denial of reimbursement for services already provided and bureaucratic interference in patient care. Totals of 46.3 and 45.9 percent, respectively, called these problems "critical." Interestingly, a total of 26.8 percent of respondents considered bureaucratic interference only a minor problem or not a problem at all in the program. Excessive paperwork was rated as a critical problem by well over a third of all respondents (36.9 percent) and a major problem by another two fifths (40.6 percent). Combining these two categories, in, fact, results in an evaluation that this problem is more important than that of bureaucratic interference in patient care. Slightly lower in severity are the delays experienced by physicians in receiving payment for services and their inability to determine the amount they will be paid for services. Approximately two thirds of all respondents consider each of these problems either critical or major. With reference to delays, a gastroenterologist in Orange County commented: We have a deadline of 2 months to get our claims in, yet we have claims that have not been paid by Medi-Cal for over a year. When inquiries are sent, we receive a letter-"Claims are being processed. No further inquiries needed."
An obstetrician/gynecologist in the same community, concerned with the problem of being able to determine how reimbursements are based, said: Doctors receive different fees for obstetrical care even though all have charged the same. There is a $41 difference depending on the doctor billing. We have contacted the representative and submitted documentation as requested but never receive answers to our inquiry.
Lowest ranked among the seven suggested THE WESTERN JOURNAL OF MEDICINE
79
MEDI-CAL SURVEY
cal specialties (dermatology, allergy, pediatrics) and psychiatry consider this more of a problem than do other physicians. A psychiatrist from Santa Clara County said, for example:
problem areas is that of difficulties experienced by physicians in securing prior authorization to provide care. Well over half of all respondents consider this problem critical in nature, however, while just over 14.8 percent indicated it is not a problem for them. In obvious frustration, a Los Angeles general practitioner remarked:
My practice is largely concerned with long term psychotherapy. Authorization is given for short times and I must watch expiration dates and submit new requests or lose payment. This situation plus the uncertainty of obtaining continuing authorizations more than any other reason causes me to limit my participation.
To sit on the phone for 45 minutes to get authorization is an unbelievable waste of time!
Who Rates Which Situations "Critical" Some of the more crucial problems showed an association with specific variables such as medical specialty or geographic area in which physicians practice. Although detailed data concerning these relationships cannot be included in this report, the following highlights are extracted from the full report of findings. The problem of inadequate level of reimbursement under Medi-Cal is considerably more critical for surgeons of all types and somewhat more so for psychiatrists than for other types of physicians. A Los Angeles orthopedic surgeon, for example, provided the following example:
The problem of denial of reimbursement for services already provided appears to be particularly acute among certain surgical specialties, such as general surgery, ophthalmology, otolaryngology and orthopedic surgery. Almost all internists called it either critical or major. An Orange County otolaryngologist commented, for example: We have recently written off over $400 of services which were authorized but have never been paid even after all of the initial paperwork and the follow-up work.
Almost half of general and family practitioners (49.2 percent) consider this problem critical. One general practitioner from San Diego, who no longer accepts Medi-Cal patients, stated:
I adjusted my accounts down over $900 on my usual and customary fees in January 1975; these were all Medi-Cal patients.
During my last year of real participation, twothirds of bills were denied after service rendered, even though prior authorization was obtained. Entire program has been handled by state officials in an arbitrary and unreasonable and incompetent man-
A San Francisco neurosurgeon commented: A professional responsibility is increasing relative to my patients, the financial return is getting less and less for my efforts at patient care. I receive approximately 60 cents return for every $1 billed for MediCal patients, with no increase in my fees in 5 years.
The problem of excessive paperwork appears to be considered more critical by surgeons than
Although the factor of difficulty in securing prior authorization ranked lowest in overall terms, it is nonetheless relevant and data concerning its association with medical specialty and with geographic area are of importance in evaluating the functioning of the program. Physicians in the fields of neurosurgery, plastic surgery, thoracic surgery, urology, internal medicine (including its subspecialties), "other" medi-
by physicians in medical specialties. A substantial majority of ophthalmologists, otolaryngologists, orthopedic surgeons and general surgeons consider this problem either critical or major. On the other hand, relatively fewer internists, physicians in "other" medical specialties (pediatrics, dermatology, allergy) and in "other" surgical specialties (neurosurgery, plastic surgery, thoracic surgery, urology) consider the problem critical.
ner.
TABLE 6.-Respondent Agreement or Disagreement with Various Statements Concerning Effects of the Treatment Authorization Request (TAR) System
Statement
Treatment is often delayed ..... ....... System interferes with case management . Follow-up care reduced or denied ...... Inconsistencies due to ill-defined criteria . Needed treatment is often denied ......
Response
Total Responding'
Agree
Number Percent
Number Percent
186 186 177 165 166
100 100 100 100 100
144 153 128 141 90
Disagree
77.4 82.3 72.3 85.5 54.2
Number Percent
42 33 49 24 76
22.6 17.7 27.7 14.5 45.8
'Excludes physicians without a TAR requirement in their area and those who indicated "don't know" or who did not respond to specific portions of question.
80
JANUARY 1976 *
124 *
1
MEDI-CAL SURVEY
Other Insights into Problem Areas The full report of findings also provides information about problem areas physicians consider most serious within the program, according to medical specialty, geographic area and current degree of involvement in Medi-Cal. The following are some highlights: * Ophthalmologists, otolaryngologists, orthopedic surgeons, psychiatrists, physicians heavily involved in Medi-Cal and physicians who are willing to accept new Medi-Cal patients are particularly concerned about excessive paperwork requirements. One psychiatrist put it this way: When considering that I do not get my usual fee, and that I do not get paid for the time spent in the enormous amount of paperwork required, I conclude that I provide an awful lot of free service. I am willing to do this for patients with whom I have developed a physician-patient relationship before they went on Medi-Cal, but not otherwise.
* Low levels of physician reimbursement are considered especially critical by general surgeons, obstetrician/gynecologists, orthopedic surgeons, practitioners in Orange County, San Diego County, and the west Bay Area, and physicians who plan to accept no new Medi-Cal patients. As a Los Angeles internist said: I would be glad to do the paperwork, carry the accounts receivable (often 9 to 12 months) if my secretary's time were reimbursed and my usual and customary fee were paid. But $6 for an office visit and $7 for a 2 a.m. emergency room visit is ridiculous if the patient takes more than 3 to 5 minutes of my time.
* Retroactive denial of reimbursement is particularly critical to physicians in "other" medical
specialties (pediatrics, dermatology, etc.), to physicians in the Bay Area and in Orange County, and to physicians who plan to continue accepting new Medi-Cal patients. A general surgeon from San Bernardino County noted the following: Our major problem is in emergency surgery cases with retroactive authorization. The hospital is usually paid. The surgeon is rarely paid. We have no choice other than treat people and I feel we should have at least some pay.
* Bureaucratic interference in patient care constitutes a special problem for general and family practitioners, ophthalmologists, otolaryngologists, "other" surgeons (neurosurgery, plastic surgery, thoracic surgery, urology), physicians in Los Angeles County, physicians who do not treat Medi-Cal patients and those who indicated that they only "might" accept a new Medi-Cal patient
for care. One Los Angeles psychiatrist made this observation: I can understand the need to restrict certain care, but it is to painful for me to have to deny a patient after we have started the program.
TAR's Cause Several Concerns Table 6 provides information about respondent opinion concerning the effect of the treatment authorization request (TAR) system. Respondents were asked to agree or disagree with each of five possible effects of the system in terms of its pertinence to their own particular experience with the Medi-Cal program. Among those who were sufficiently familiar with the system to respond, the area of concern with which most agreed (85.5 percent) was that the system results in "inconsistencies due to apparently ill-defined criteria." A psychiatrist from San Diego said: "Since the Medi-Cal rules fluctuate, the procedures are unclear and require excessive amounts of time to unravel." Significant proportions of physicians also felt that the system interferes with case management (82.3 percent), that treatment is often delayed (77.4 percent) and that appropriate follow-up care is often reduced or denied (72.3 percent). Regarding the problem of follow-up care, one orthopedic surgeon from Orange County said: A major problem in orthopedics is obtaining adequate post injury or post operative physical therapy -enough of a problem that the patient is better off being referred to a county facility for any surgical procedure which requires post-op. therapy.
Only a slight majority (54.2 percent) agreed with the proposal that "needed treatment is often denied." However, there was little consistency in the thinking of respondents with respect to this issue. Although not shown in the tabular data, certain associations between this problem and medical specialty, as well as geographic area, appear to exist. The problem of treatment denial is particularly prevalent among internists, psychiatrists and physicians in "other" medical specialties such as dermatology and pediatrics, as well as among general and family practitioners. A Los Angeles cardiologist commented, for example: The biggest problem I face is the statutory limitation on the kinds and amounts of service I can render. Most of my patients are chronically ill with multiple system disease. On a full day I see maybe 8 to 10 people. This is so out of phase with what Medi-Cal will allow, that I will not work with a Medi-Cal recipient unless 1 have some personal commitment to that person or their family.
THE WESTERN JOURNAL OF MEDICINE
81
MEDI-CAL SURVEY TABLE 7.-Frequency with Which Respondents Experience Retrospective Denial Resulting in Nonpayment for Services Rendered to Medi-Cal Patients, According to Medical Specialty Total Responding' Number Percent
Medical Specialty
Frequency of Occurrence Seldom Occasionally
Frequently Number Percent
Number Percent
Number Percent
14.5 6.4 29.4 23.1 25.0
4 3 2 1 0
7.3 6.4 11.8 7.7
0 2 2 2 0
13.3 16.7 10.0
2
33.3 8.3 25.0 22.2
35
16.7
16
7.7
55 General/Family Practice Internal Medicine2 ......... 47 Other Medicine. ........... 17 General Surgery4 ......... 13 12 Obstetrics/Gynecology. Ophthalmology/ 9 Otolaryngology. Orthopedic Surgery ........ 15 Other Surgery5 ............ 12 Psychiatry ................ 20 9 All Other .................
100 100 100 100 100
19 16 3, 4 3
34.5 34.0 17.6 30.8 25.0
24 25 7 5 6
43.6 53.2 41.2 38.5 50.0
8 3 5 3 3
100 100 100 100 100
2 2 3 2 0
22.2 13.3 25.0 10.0
7 6 6 11 7
77.8 40.0 50.0 55.0 77.8
0
Total .................... 209
100
54
25.8
104
49.8
'Excludes physicians without a TAR requirement in their area and those who indicated "don't know" or who did not respond to specific portions of question. 2Includes subspecialties. 3Includes allergy, dermatology, neurology, physical medicine.
Never
Number Percent
1
*S
4Includes abdominal surgery, colon and rectal surgery, pediatric surgery. 5Includes cardiovascular surgery, neurological surgery, plastic surgery, thoracic surgery, urology.
TABLE 8.-Respondent Opinion Concerning Medical Advisors Within the Medi-Cal System, According to Selected Areas and for the State Opiniont Total
Responding' Geographic Area
Number Percent
Alameda/ Contra Costa Los Angeles
Understanding Number Percent
Fair Number Percent
Inconsistent
Number Percent
Arbitrary Nuwnber Percent
Dollar Oriented Number Percent
20 66 18 Orange. San Diego .12 16 Santa Clara .
100 100 100 100 100
6 11 3 6 6
30.0 16.7 16.7 50.0 37.5
4 11 4 2 1
20.0 16.7 22.2 16.7 6.2
4 16 7 2 4
20.0 24.2 38.9 16.7 25.0
3 9 2 0 2
15.0 13.6 11.1 .. 12.5
3 19 2 2 3
15.0 28.8 11.1 16.7 18.8
Riverside/ San Bernardino. Other Areas .
10 55
100 100
5 21
50.0 38.2
0 6
.. 10.9
2 12
20.0 21.8
0 3
.. 5.5
3 13
30.0 23.6
197
100
58
29.4
28
14.2
47
23.9
19
9.6
45
22.8
Total State
.
'Excludes physicians who did not respond to specific question.
With respect to geographic area, almost four out, of five respondents in Los Angeles County acknowledged a problem of treatment denial. Conversely, the situation appears much less prevalent in areas such as San Diego, Santa Clara, Riverside and San Bernardino Counties, as well as in counties where there were too few respondents to permit individual identification. In most cases, these counties are smaller metropolitan areas or rural areas. Several respondents commented that they try to avoid the necessity of securing a TAR, often merely absorbing the cost of providing the service. As one Los Angeles internist put it: We do not ask for TAR unless absolutely necessary. We cannot turn a seriously ill patient away so we see them whether we receive payment for the treatment or not. We feel this is an unfair situation.
82
JANUARY 1976 *
124 *
1
2See text for full content of statements.
Many Experience Retrospective Denial Table 7 relates to the problem of retrospective denial and how frequently it results in nonpayment for services already provided, according to medical specialty. Among all respondents, slightly over a fourth (25.8 percent) indicated that they often experience retroactive denial, while almost half (49.8 percent) indicated that they experience it occasionally. The remaining respondents stated that the problem seldom (16.7 percent) or never (7.7 percent) occurs. Over a third of respondents in general and family practice (34.5 percent) and in internal medicine (34.0 percent) indicated that the problem often occurs, while relatively few orthopedic surgeons (13.3 percent) or psychiatrists (10.0 percent) have experienced this situation. An ex-
MEDI-CAL SURVEY
ample of the frustrations physicians experience in securing payment for services already provided are the following comments of a Los Angeles internist: The most galling factor is as follows: a bill is submitted by this office for Medi-Cal services. Many months go by . . . no answer. A follow-up tracer letter is written asking for payment. Again many months go by. Finally 2 payments are made for 2 months, and 2 payments for 2 visits during earlier months are not. Attempts to receive explanation by long distance telephone, correspondence (from Los Angeles to San Francisco) is like putting your body into a barrel of taffy. The harder you try, the more involved you get. The stupid answers one gets from the retarded personnel employed by Medi-Cal is enough to raise my renin-angiotensin levels to astronomical heights. Finally, in desperation and total frustration, I hang up, turn to my secretary and state: "Write the damn unpaid bill off and don't take any more Medi-Cal patients." . . . and that's where it stands today. It is amazing how efficiently that Medicare bills are paid and how promptly I receive answers to any inquiries I might make.
Medical Advisors Elicit Mixed Reactions Table 8 provides information about respondent opinion of medical advisors within the Medi-Cal system according to geographic area. Among all respondents, most felt that medical advisors were at best inconsistent in handling requests for authorization. As one general practitioner commented: "Personal idiosyncrasies of the medical consultant are impossible to overrule." A substantial minority (22.8 percent) felt that advisors appear more concerned with the money than with patient care, while a considerably smaller but nevertheless significant group (9.6 percent) indicated that advisors are often arbitrary in dealing with requests for authorization. At the other end of the spectrum, almost three respondents in ten (29.4 percent) felt that medical advisors are generally understanding and willing to authorize recommended treatment, while another large group (14.2 percent) were of the opinion that medical advisors are fair but stringent in providing treatment authorization. A family practitioner
from San Diego expressed the feeling that advisors are "hamstrung by state regulations." Respondents in Los Angeles County were particularly critical of medical advisors, while those in Alameda, Contra Costa, Orange and San Diego counties appeared to be somewhat less critical. Almost two respondents in five from Orange County (38.9 percent) indicated that advisors are inconsistent in handling requests for authorization. In San Diego and in the Riverside-San Bernardino area, however, half of all respondents indicated that advisors are '"generally understanding." Although not shown in the tabular data, findings show that there is only a limited degree of association between physician opinions about medical advisors and medical specialty. However, physicians in strictly medical specialties (internal medicine, pediatrics, dermatology and so forth) tend to be somewhat more critical of medical advisors or of the system, than do physicians in most other specialties. An internist in Santa Clara County said: It is seldom that we are able to communicate with the medical advisor personally. Most requests are relayed to him (and his questions to me) through a clerk who has little medical knowledge.
A General Practitioner Sums It Up Summing up various concerns with the MediCal program experienced by physicians, especially those with considerable involvement in the program, one general practitioner from Alameda County made the following comments: I practice in a high Medi-Cal area, and I refuse three or four new Medi-Cal patients per week. I quit taking new patients when the total came to 25 percent of my practice. Since my expenses are about 50 percent of my receipts, I felt very uneasy about having half of my personal income dependent on Medi-Cal, to be reduced or deferred as they see fit. I would accept more Medi-Cal patients if I could feel that the program was dedicated to fair treatmen of both patient and doctors.
THE WESTERN JOURNAL OF MEDICINE
83
Information
Survey of Physician Participation in and Dissatisfaction with the Medi-Cal Program A
MICHAEL W. JONES, MBA, and BETTE HAMBURGER, BA, San Francisco A Socioeconomic Report of the Bureau of Research and Planning California Medical Association
IN LATE 1974, the California Medical Association's Bureau of Research and Planning sent questionnaires about participation in Medi-Cal (California's Medicaid program) to a random sample of 1,200 members in private medical practice. Questions covered degree of current participation in the program; plans for future participation; patterns of acceptance of new Medi-Cal patients, referrals and consultations, and similar questions about personal involvement in the program. Responses were received from almost 70 percent of physicians sampled. Subsequently, respondents who have curtailed participation in Medi-Cal or plan to do so were sent a follow-up questionnaire to elicit information about their perception of various problem areas within the program. From these data, evaluations can be made concerning the types of reform that might be most fruitful in eliciting the broadscale physician participation on which the program is conceptually based. Well over threequarters of the 336 physicians in this subsample group provided data. These findings represent highlights of a detailed report, single copies of which are available on request from the CMA's Division of Research and Socioeconomics. Mr. Jones is Director of the Division of Research and Socioeconomics, California Medical Association. Ms. Hamburger is a Research Assistant and Staff Coordinator. Reprint requests to Bureau of Research and Planning, California Medical Association, 731 Market Street, San Francisco, California 94103.
Part I-The Broad-Scale Sample Most Physicians Participate in Medi-Cal Program As seen in Table 1, approximately one patient in ten (9.7 percent) being treated by the average physician is covered under the Medi-Cal program. However, the table clearly shows that a substantial number of physicians (14.9 percent) practice in a situation where over a quarter of all their patients are under Medi-Cal, while a relatively small proportion (6.3 percent) treat no Medi-Cal patients whatever. More than a fourth of all respondents (25.6 percent) conduct practices in which fewer than 5 percent of their patients are on Medi-Cal. Understandably, participation differs according to medical specialty. Pediatricians tend to have a relatively higher proportion of Medi-Cal patients than do most other physicians, while internists, obstetrician/gynecologists and orthopedists have below-average proportions. Many pediatricians, general practitioners and psychiatrists have a patient load of which more than a fourth is made up of Medi-Cal patients. At the other end of the spectrum, above average proportions of obstetrician/gynecologists and psychiatrists treat no Medi-Cal patients whatever. One psychiatrist, who formerly treated Medi-Cal patients, commented that he would participate "only if Medi-Cal patients would be permitted as many visits as were necessary to help them." THE WESTERN JOURNAL OF MEDICINE
75
MEDI-CAL SURVEY
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JANUARY 1976 *
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1
Few Respondents Want More Medi-Cal Patients Table 2 provides information about patterns of acceptance of new Medi-Cal patients, according to medical specialty. Data from anesthesiologists, radiologists and pathologists have been excluded, since they are generally unable to make an independent decision about whom they treat. Also excluded are data from respondents who have never treated Medi-Cal patients. Among other respondents, 43.1 percent probably would accept a new Medi-Cal patient, 19.9 percent might accept one, 24.6 percent probably would not accept one and 12.4 percent definitely would not accept a new Medi-Cal patient. Thus, it is clear that only a minority of California's private practitioners would willingly provide care to a new Medi-Cal patient seeking their services if the circumstances were such that they could make such a choice. Data about physician willingness to accept new Medi-Cal patients according to their current level of participation are also shown in Table 2. Excluded from this portion of the table are respondents who indicated that they have never treated patients under the program; included, however, are anesthesiologists, radiologists and pathologists. The data show a close association between degree of current Medi-Cal involvement and willingness to continue treating patients under the program. Among physicians whose case load is currently over a quarter Medi-Cal patients, almost four out of five respondents (79.8 percent) indicated that they probably would accept a new Medi-Cal patient who requested care, while just over 10 percent indicated that they either probably or definitely would not accept a new MediCal patient seeking services at this time. At the low end of the spectrum of current Medi-Cal participation, more than six out of ten respondents (63.4 percent) indicated that they probably would not or definitely would not accept a new Medi-Cal patient, while fewer than a fourth (22.8 percent) said that they probably would accept one. This close association suggests that the base of Medi-Cal participation by California
MEDI-CAL SURVEY TABLE 2.-Acceptance of New Medi-Cal Patients, by Medical Specialty and Level of Current Involvement in the Program
Specialty/Lev el of
Current Participation
Total Respondents Number Percent
Probably Would Number Percent
Acceptance of New Medi-Cal Patients Probably Not Might Percent Number Number Percent
General/Family Practice .... 155 ........ 121 Internal Medicine1 .. Pediatrics' . ................ 41 Other Medical2 .31 General Surgery3. .......... 57 Other Surgery4. ............ 32 57 ..... Obstetrics/Gynecology Ophthalmology ....... ..... 37 Orthopedic Surgery ........ 33 Otolaryngology ....... ..... 19 Psychiatry1 ................ 54 All Other ................ 26 Total (excluding Anesthesiology, Radiology and Pathology)5 663 24 Formerly treated, none now Under 5 percent ...... ..... 189 S to 10 percent ....... ..... 156 11 to 15 percent ...... ..... 127 16 to 25 percent ...... ..... 109 Over 25 percent ...... ..... 109
100 100 100 100 100 100 100 100 100 100 100 100
52 30 23 18 32 18 24 28 10 13 24 14
33.5 24.8 56.1 58.1 56.1 56.3 42.1 75.7 30.3 68.4 44.4 53.8
32 23 11 3 11 7 13 3 6 6 13 4
20.6 19.0 26.8 9.7 19.3 21.9 22.8 8.1 18.2 31.6 24.1 15.4
100 100 100 100 100 100 100
286
69 87
43.1 4.2 22.8 42.3 48.8 63.3 79.8
132 1 34 35 33 20 11
19.9 4.2 18.0 22.4 26.0 18.3 10.1
Totals...................... 714
100
328
45.9
134
18.8
1 43 66 62
37
23.9 42.1 12.2 25.8 17.5 18.8 28.1 10.8 33.3
Definitely Not Number Percent
21.9 14.1 4.9 6.5 7.0
18.5 19.2
34 17 2 2 4 1 4 2 6 0 7 3
163 9 77 35 22 15 7
24.6 37.5 44.9 22.4 17.3 13.8 6.4
82 13 35 20 10 5 4
12.4 54.2 18.5 12.8 7.9 4.6 3.7
165
23.1
87
12.2
51 5 8 10 6 16 4 11 0 10 5
3.1 7.0
5.4 18.2
13.0 11.5
6Excludes physicians who have never treated any Medi-Cal patients.
14See footnotes to Table 1. 5Excludes 23 respondents who have never treated Medi-Cal patients, and 8 who did not respond to this specific question.
TABLE 3.-Physicians' Continued Treatment of Current Medi-Cal Patients During the Coming Year by Medical Specialty and Level of Current Involvement in the Program
Specialty/Level of
Current Participation
Total Respondents Number Percent
General/Family Practice .... 154 Internal Medicine1 . ........ 119 Pediatrics'. ................ 41 Other Medical2. ............ General Surgery .55.......... Other Surgery4. ............ ..... Obstetrics/Gynecology
Ophthalmology ....... ..... Orthopedic Surgery ........ Otolaryngology ....... ..... Psychiatry' ...............
29 S 30 52 36 31 19 49 26
All Other ................ Total (excluding Anesthesiology, Radiology and Pathology)5 . 641 Under 5 percent ........... 190 5 to 10 percent ........... 156 11 to 15 percent ........... 126 16 to 25 percent ........... 109 Over 25 percent ........... 110 Total6 .691
Continue, Plus Family Members Number Percent
Treatment of Current Medi-Cal Patients Gradually Lower Continue Number of Patients Patients Only Number Percent Number Percent
Number Percent
22 21 2 4 9 7 11 3 9 1 13 7
14.3 17.6 4.9 13.8 16.4 23.3 21.1 8.3 29.0 5.3 26.5 26.9
7 11 1 1 4 3 4 1 2 0 3 4
7.3 10.0 7.7 2.8 6.5
4
17.5 34.5 14.6 27.6 18.2 10.0 23.1 8.3 32.3 .. 14.3 15.4
61.5 78.2
131 61 27 26 12 9
20.4 32.1 17.3 20.6 11.0 8.2
109 27 30 21 25 13
17.0 14.2 19.2 16.7 22.9 11.8
41 26 7 5 5 2
6.4 13.7 4.5 4.0 4.6 1.8
57.2
135
19.5
116
16.8
45
6.5
100 100 100 100 100 100 100 100 100 100 100 100
98 46 32 16 32 17 25 29 10 18 26 11
63.6 38.7 78.0 55.2 58.2 56.7 48.1 80.6 32.3 94.7
53.1
27 41 6 8 10 3 12 3 10 0 7
42.3
100 100 100 100 100 100
360 76 92 74 67 86
56.2 40.0 59.0
100
395
2-4See footnotes to Table 1. 5Excludes 23 respondents who have never treated Medi-Cal patients, 24 who have no current Medi-Cal patients, and 7 who did not respond to this specific question.
Curtail Number of Patients Soon
58.7
zExcludes physicians
with no Medi-Cal
4.5 9.2
2.4 3.4
6.1
15.4
patients currently
their care.
THE WESTERN JOURNAL OF MEDICINE
77
under
MEDI-CAL SURVEY TABLE 4.-Medi-Cal Patient Load Expected in Three Years, by Current Level of Program Participation Total Respondents Number Percent
Proportion of Patients Under Medi-Cal
Under 5 percent ..... 5 to 10 percent ...... 11 to 15 percent ..... 16 to 25 percent ..... Over 25 percent ......
Proportion of Medi-Cal Patients in Three Years Larger
Same
Number Percent
Number Percent
Smaller
Nutmber Percent
No Answer Nuimber Percent
191 158 129 109 I 11.....
100 100 100 100 100
14 18 24 33 40
7.3 11.4 18.6 30.3 36.0
99 97 66 57 46
51.8 61.4 51.2 52.3 41.4
72 42 36 19 23
37.7 26.6 27.9 17.4 20.7
6 1 3 0 2
3.1 0.6 2.3
Total' ..................... 698 No Medi-Cal Patients Currently Under Care .... 47
100
129
18.5
365
52.3
195
27.5
12
1.7
100
3
6.4
44
93.6
0
0.0
0
0.0
.....
..... ..... .....
1.8
'Excludes physicians with no Medi-Cal patients currently under their care.
physicians is gradually narrowing and that, absent program changes, the future will find fewer physicians treating more patients under the program. Many Plan to Curtail Medi-Cal Involvement Table 3 provides information about the future plans of physicians who are currently treating Medi-Cal patients. Most physicians indicated that they will continue treating Medi-Cal patients, as well as family members. However, a substantial proportion (17.0 percent) intend gradually to lower the number of Medi-Cal patients under their care, while some others (6.4 percent) plan to curtail caring for Medi-Cal patients as rapidly as feasible. Internists and orthopedists showed particular reluctance to offer services to "family members" not currently under their care. "Other" surgeons, such as neurosurgeons and urologists, obstetrician/gynecologists, orthopedists and psychiatrists seem especially anxious to lower the proportion of Medi-Cal patients under their care. This proposed course of action was noted by very few pediatricians, ophthalmologists or otolaryngologists. Information about future plans regarding MediCal participation according to level of current involvement by physician respondents is also contained in Table 3. Most physicians with significant current involvement expect to remain involved, while those with a low level of participation plan to limit their participation even more or, in fact, curtail it entirely. The data again show that the base of physicians available to provide care under the program is narrowing and that relatively more care will be provided in the future by those physicians who already have significant involvement in the program. 78
JANUARY 1976 * 124 * 1
Further Evidence of Narrowing Base As seen in Table 4, most respondents (52.3 percent) indicated that they expect the proportion of Medi-Cal patients under their care in three years to be similar to the current proportion. Among others, 27.5 percent plan to be treating a smaller proportion. Since it is unlikely that many respondents expect the program itself to contract, one can assume that this group of respondents propose to achieve a diminished proportion by reason of their own voluntary actions with respect to participation in the program. While only 7.3 percent of physicians whose current case load is under 5 percent Medi-Cal expect to increase this proportion, almost two in five (37.7 percent) plan to reduce it. Conversely, among those physicians whose current complement of patients is over a fourth Medi-Cal, well over a third (36.0 percent) expect to be treating an even larger proportion in the future, while only one in five (20.7 percent) expect the proportion to diminish. Although the association between these two variables is extremely close, it should also be noted that a small but nonetheless significant proportion of physicians who are heavily involved in the program apparently wish to curtail their degree of involvement. The data also suggest that an almost negligible proportion of physicians not currently treating any Medi-Cal patients expect to begin participating in the program in the future. Although not shown in Table 4, among physicians who expect to be treating relatively more Medi-Cal patients, an overwhelming majority indicated that this is based on their own feeling of responsibility. Many also anticipate that more Medi-Cal patients will be seeking a new physician in the future. Relatively few physicians considered
MEDI-CAL SURVEY TABLE 5.-Respondent Ratings of Various Potential Problem Areas in the Medi-Cal Program Total
Problem Area
Responding' Number Percent
Inability to deteFmine amount Mb will be paid ........ 243 Excessive paperwork ....... 249 Delays in payment .......... 243 Difficulty in securing prior authorization ...... ..... 230 Inadequate level of reimbursement ........... 244 Denial of reimbursement for services provided . 231 Bureaucratic interference with patient care .242
Critical Number Percent
Seriousness of Problem Minor Major Number Percent Number Percent
Not a Problem Number Percent
100 100 100
57 92 73
23.5 36.9 30.0
109 101 83
44.9 40.6 34.2
62 52 66
25.5 20.9 27.2
15 4 21
6.2
100
43
18.7
83
36.1
70
30.4
34
14.8
100
125
51.2
90
36.9
26
10.7
3
1.2
100
107
46.3
81
35.1
27
11.7
16
6.9
40
16.5
25
10.3
1.6 8.6
I
100
111
45.9
66
27.3
'Excludes physicians who indicated "don't know" or who did not respond to specific portions of the question.
the program "reasonably easy to work with," while an almost negligible proportion indicated a preference for Medi-Cal patients to other types of patients. Almost half of these respondents expected that they would be treating a larger proportion of Medi-Cal patients because other physicians in their geographic area are limiting their Medi-Cal practice.
Part Il-The Follow-Up Who Provided the Data Information contained in the follow-up survey is based on responses from a sample of 336 California Medical Association members who, in answer to Part I of the "Medi-Cal Participation Survey," indicated that they either treat no patients under the Medi-Cal program or had cut back on their participation or planned to do so in the future. This represents 45 percent of the total group of physicians who responded to the earlier questionnaire. Usable responses were received from 258 of the 336 physicians sampled, or 76.8 percent. This high rate of response assures that the data represent with reasonable accuracy the opinions of physicians sufficiently alienated by Medi-Cal to have taken action with respect to their own personal participation in the program. Medi-Cal Problem Areas Identified Table 5 indicates how respondents rated various potential problem areas within the MediCal program. Over half of all respondents (51.2 percent) consider inadequate level of reimbursement a critical problem to them with reference to participation in the Medi-Cal program. Almost
as important are the problems of denial of reimbursement for services already provided and bureaucratic interference in patient care. Totals of 46.3 and 45.9 percent, respectively, called these problems "critical." Interestingly, a total of 26.8 percent of respondents considered bureaucratic interference only a minor problem or not a problem at all in the program. Excessive paperwork was rated as a critical problem by well over a third of all respondents (36.9 percent) and a major problem by another two fifths (40.6 percent). Combining these two categories, in, fact, results in an evaluation that this problem is more important than that of bureaucratic interference in patient care. Slightly lower in severity are the delays experienced by physicians in receiving payment for services and their inability to determine the amount they will be paid for services. Approximately two thirds of all respondents consider each of these problems either critical or major. With reference to delays, a gastroenterologist in Orange County commented: We have a deadline of 2 months to get our claims in, yet we have claims that have not been paid by Medi-Cal for over a year. When inquiries are sent, we receive a letter-"Claims are being processed. No further inquiries needed."
An obstetrician/gynecologist in the same community, concerned with the problem of being able to determine how reimbursements are based, said: Doctors receive different fees for obstetrical care even though all have charged the same. There is a $41 difference depending on the doctor billing. We have contacted the representative and submitted documentation as requested but never receive answers to our inquiry.
Lowest ranked among the seven suggested THE WESTERN JOURNAL OF MEDICINE
79
MEDI-CAL SURVEY
cal specialties (dermatology, allergy, pediatrics) and psychiatry consider this more of a problem than do other physicians. A psychiatrist from Santa Clara County said, for example:
problem areas is that of difficulties experienced by physicians in securing prior authorization to provide care. Well over half of all respondents consider this problem critical in nature, however, while just over 14.8 percent indicated it is not a problem for them. In obvious frustration, a Los Angeles general practitioner remarked:
My practice is largely concerned with long term psychotherapy. Authorization is given for short times and I must watch expiration dates and submit new requests or lose payment. This situation plus the uncertainty of obtaining continuing authorizations more than any other reason causes me to limit my participation.
To sit on the phone for 45 minutes to get authorization is an unbelievable waste of time!
Who Rates Which Situations "Critical" Some of the more crucial problems showed an association with specific variables such as medical specialty or geographic area in which physicians practice. Although detailed data concerning these relationships cannot be included in this report, the following highlights are extracted from the full report of findings. The problem of inadequate level of reimbursement under Medi-Cal is considerably more critical for surgeons of all types and somewhat more so for psychiatrists than for other types of physicians. A Los Angeles orthopedic surgeon, for example, provided the following example:
The problem of denial of reimbursement for services already provided appears to be particularly acute among certain surgical specialties, such as general surgery, ophthalmology, otolaryngology and orthopedic surgery. Almost all internists called it either critical or major. An Orange County otolaryngologist commented, for example: We have recently written off over $400 of services which were authorized but have never been paid even after all of the initial paperwork and the follow-up work.
Almost half of general and family practitioners (49.2 percent) consider this problem critical. One general practitioner from San Diego, who no longer accepts Medi-Cal patients, stated:
I adjusted my accounts down over $900 on my usual and customary fees in January 1975; these were all Medi-Cal patients.
During my last year of real participation, twothirds of bills were denied after service rendered, even though prior authorization was obtained. Entire program has been handled by state officials in an arbitrary and unreasonable and incompetent man-
A San Francisco neurosurgeon commented: A professional responsibility is increasing relative to my patients, the financial return is getting less and less for my efforts at patient care. I receive approximately 60 cents return for every $1 billed for MediCal patients, with no increase in my fees in 5 years.
The problem of excessive paperwork appears to be considered more critical by surgeons than
Although the factor of difficulty in securing prior authorization ranked lowest in overall terms, it is nonetheless relevant and data concerning its association with medical specialty and with geographic area are of importance in evaluating the functioning of the program. Physicians in the fields of neurosurgery, plastic surgery, thoracic surgery, urology, internal medicine (including its subspecialties), "other" medi-
by physicians in medical specialties. A substantial majority of ophthalmologists, otolaryngologists, orthopedic surgeons and general surgeons consider this problem either critical or major. On the other hand, relatively fewer internists, physicians in "other" medical specialties (pediatrics, dermatology, allergy) and in "other" surgical specialties (neurosurgery, plastic surgery, thoracic surgery, urology) consider the problem critical.
ner.
TABLE 6.-Respondent Agreement or Disagreement with Various Statements Concerning Effects of the Treatment Authorization Request (TAR) System
Statement
Treatment is often delayed ..... ....... System interferes with case management . Follow-up care reduced or denied ...... Inconsistencies due to ill-defined criteria . Needed treatment is often denied ......
Response
Total Responding'
Agree
Number Percent
Number Percent
186 186 177 165 166
100 100 100 100 100
144 153 128 141 90
Disagree
77.4 82.3 72.3 85.5 54.2
Number Percent
42 33 49 24 76
22.6 17.7 27.7 14.5 45.8
'Excludes physicians without a TAR requirement in their area and those who indicated "don't know" or who did not respond to specific portions of question.
80
JANUARY 1976 *
124 *
1
MEDI-CAL SURVEY
Other Insights into Problem Areas The full report of findings also provides information about problem areas physicians consider most serious within the program, according to medical specialty, geographic area and current degree of involvement in Medi-Cal. The following are some highlights: * Ophthalmologists, otolaryngologists, orthopedic surgeons, psychiatrists, physicians heavily involved in Medi-Cal and physicians who are willing to accept new Medi-Cal patients are particularly concerned about excessive paperwork requirements. One psychiatrist put it this way: When considering that I do not get my usual fee, and that I do not get paid for the time spent in the enormous amount of paperwork required, I conclude that I provide an awful lot of free service. I am willing to do this for patients with whom I have developed a physician-patient relationship before they went on Medi-Cal, but not otherwise.
* Low levels of physician reimbursement are considered especially critical by general surgeons, obstetrician/gynecologists, orthopedic surgeons, practitioners in Orange County, San Diego County, and the west Bay Area, and physicians who plan to accept no new Medi-Cal patients. As a Los Angeles internist said: I would be glad to do the paperwork, carry the accounts receivable (often 9 to 12 months) if my secretary's time were reimbursed and my usual and customary fee were paid. But $6 for an office visit and $7 for a 2 a.m. emergency room visit is ridiculous if the patient takes more than 3 to 5 minutes of my time.
* Retroactive denial of reimbursement is particularly critical to physicians in "other" medical
specialties (pediatrics, dermatology, etc.), to physicians in the Bay Area and in Orange County, and to physicians who plan to continue accepting new Medi-Cal patients. A general surgeon from San Bernardino County noted the following: Our major problem is in emergency surgery cases with retroactive authorization. The hospital is usually paid. The surgeon is rarely paid. We have no choice other than treat people and I feel we should have at least some pay.
* Bureaucratic interference in patient care constitutes a special problem for general and family practitioners, ophthalmologists, otolaryngologists, "other" surgeons (neurosurgery, plastic surgery, thoracic surgery, urology), physicians in Los Angeles County, physicians who do not treat Medi-Cal patients and those who indicated that they only "might" accept a new Medi-Cal patient
for care. One Los Angeles psychiatrist made this observation: I can understand the need to restrict certain care, but it is to painful for me to have to deny a patient after we have started the program.
TAR's Cause Several Concerns Table 6 provides information about respondent opinion concerning the effect of the treatment authorization request (TAR) system. Respondents were asked to agree or disagree with each of five possible effects of the system in terms of its pertinence to their own particular experience with the Medi-Cal program. Among those who were sufficiently familiar with the system to respond, the area of concern with which most agreed (85.5 percent) was that the system results in "inconsistencies due to apparently ill-defined criteria." A psychiatrist from San Diego said: "Since the Medi-Cal rules fluctuate, the procedures are unclear and require excessive amounts of time to unravel." Significant proportions of physicians also felt that the system interferes with case management (82.3 percent), that treatment is often delayed (77.4 percent) and that appropriate follow-up care is often reduced or denied (72.3 percent). Regarding the problem of follow-up care, one orthopedic surgeon from Orange County said: A major problem in orthopedics is obtaining adequate post injury or post operative physical therapy -enough of a problem that the patient is better off being referred to a county facility for any surgical procedure which requires post-op. therapy.
Only a slight majority (54.2 percent) agreed with the proposal that "needed treatment is often denied." However, there was little consistency in the thinking of respondents with respect to this issue. Although not shown in the tabular data, certain associations between this problem and medical specialty, as well as geographic area, appear to exist. The problem of treatment denial is particularly prevalent among internists, psychiatrists and physicians in "other" medical specialties such as dermatology and pediatrics, as well as among general and family practitioners. A Los Angeles cardiologist commented, for example: The biggest problem I face is the statutory limitation on the kinds and amounts of service I can render. Most of my patients are chronically ill with multiple system disease. On a full day I see maybe 8 to 10 people. This is so out of phase with what Medi-Cal will allow, that I will not work with a Medi-Cal recipient unless 1 have some personal commitment to that person or their family.
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MEDI-CAL SURVEY TABLE 7.-Frequency with Which Respondents Experience Retrospective Denial Resulting in Nonpayment for Services Rendered to Medi-Cal Patients, According to Medical Specialty Total Responding' Number Percent
Medical Specialty
Frequency of Occurrence Seldom Occasionally
Frequently Number Percent
Number Percent
Number Percent
14.5 6.4 29.4 23.1 25.0
4 3 2 1 0
7.3 6.4 11.8 7.7
0 2 2 2 0
13.3 16.7 10.0
2
33.3 8.3 25.0 22.2
35
16.7
16
7.7
55 General/Family Practice Internal Medicine2 ......... 47 Other Medicine. ........... 17 General Surgery4 ......... 13 12 Obstetrics/Gynecology. Ophthalmology/ 9 Otolaryngology. Orthopedic Surgery ........ 15 Other Surgery5 ............ 12 Psychiatry ................ 20 9 All Other .................
100 100 100 100 100
19 16 3, 4 3
34.5 34.0 17.6 30.8 25.0
24 25 7 5 6
43.6 53.2 41.2 38.5 50.0
8 3 5 3 3
100 100 100 100 100
2 2 3 2 0
22.2 13.3 25.0 10.0
7 6 6 11 7
77.8 40.0 50.0 55.0 77.8
0
Total .................... 209
100
54
25.8
104
49.8
'Excludes physicians without a TAR requirement in their area and those who indicated "don't know" or who did not respond to specific portions of question. 2Includes subspecialties. 3Includes allergy, dermatology, neurology, physical medicine.
Never
Number Percent
1
*S
4Includes abdominal surgery, colon and rectal surgery, pediatric surgery. 5Includes cardiovascular surgery, neurological surgery, plastic surgery, thoracic surgery, urology.
TABLE 8.-Respondent Opinion Concerning Medical Advisors Within the Medi-Cal System, According to Selected Areas and for the State Opiniont Total
Responding' Geographic Area
Number Percent
Alameda/ Contra Costa Los Angeles
Understanding Number Percent
Fair Number Percent
Inconsistent
Number Percent
Arbitrary Nuwnber Percent
Dollar Oriented Number Percent
20 66 18 Orange. San Diego .12 16 Santa Clara .
100 100 100 100 100
6 11 3 6 6
30.0 16.7 16.7 50.0 37.5
4 11 4 2 1
20.0 16.7 22.2 16.7 6.2
4 16 7 2 4
20.0 24.2 38.9 16.7 25.0
3 9 2 0 2
15.0 13.6 11.1 .. 12.5
3 19 2 2 3
15.0 28.8 11.1 16.7 18.8
Riverside/ San Bernardino. Other Areas .
10 55
100 100
5 21
50.0 38.2
0 6
.. 10.9
2 12
20.0 21.8
0 3
.. 5.5
3 13
30.0 23.6
197
100
58
29.4
28
14.2
47
23.9
19
9.6
45
22.8
Total State
.
'Excludes physicians who did not respond to specific question.
With respect to geographic area, almost four out, of five respondents in Los Angeles County acknowledged a problem of treatment denial. Conversely, the situation appears much less prevalent in areas such as San Diego, Santa Clara, Riverside and San Bernardino Counties, as well as in counties where there were too few respondents to permit individual identification. In most cases, these counties are smaller metropolitan areas or rural areas. Several respondents commented that they try to avoid the necessity of securing a TAR, often merely absorbing the cost of providing the service. As one Los Angeles internist put it: We do not ask for TAR unless absolutely necessary. We cannot turn a seriously ill patient away so we see them whether we receive payment for the treatment or not. We feel this is an unfair situation.
82
JANUARY 1976 *
124 *
1
2See text for full content of statements.
Many Experience Retrospective Denial Table 7 relates to the problem of retrospective denial and how frequently it results in nonpayment for services already provided, according to medical specialty. Among all respondents, slightly over a fourth (25.8 percent) indicated that they often experience retroactive denial, while almost half (49.8 percent) indicated that they experience it occasionally. The remaining respondents stated that the problem seldom (16.7 percent) or never (7.7 percent) occurs. Over a third of respondents in general and family practice (34.5 percent) and in internal medicine (34.0 percent) indicated that the problem often occurs, while relatively few orthopedic surgeons (13.3 percent) or psychiatrists (10.0 percent) have experienced this situation. An ex-
MEDI-CAL SURVEY
ample of the frustrations physicians experience in securing payment for services already provided are the following comments of a Los Angeles internist: The most galling factor is as follows: a bill is submitted by this office for Medi-Cal services. Many months go by . . . no answer. A follow-up tracer letter is written asking for payment. Again many months go by. Finally 2 payments are made for 2 months, and 2 payments for 2 visits during earlier months are not. Attempts to receive explanation by long distance telephone, correspondence (from Los Angeles to San Francisco) is like putting your body into a barrel of taffy. The harder you try, the more involved you get. The stupid answers one gets from the retarded personnel employed by Medi-Cal is enough to raise my renin-angiotensin levels to astronomical heights. Finally, in desperation and total frustration, I hang up, turn to my secretary and state: "Write the damn unpaid bill off and don't take any more Medi-Cal patients." . . . and that's where it stands today. It is amazing how efficiently that Medicare bills are paid and how promptly I receive answers to any inquiries I might make.
Medical Advisors Elicit Mixed Reactions Table 8 provides information about respondent opinion of medical advisors within the Medi-Cal system according to geographic area. Among all respondents, most felt that medical advisors were at best inconsistent in handling requests for authorization. As one general practitioner commented: "Personal idiosyncrasies of the medical consultant are impossible to overrule." A substantial minority (22.8 percent) felt that advisors appear more concerned with the money than with patient care, while a considerably smaller but nevertheless significant group (9.6 percent) indicated that advisors are often arbitrary in dealing with requests for authorization. At the other end of the spectrum, almost three respondents in ten (29.4 percent) felt that medical advisors are generally understanding and willing to authorize recommended treatment, while another large group (14.2 percent) were of the opinion that medical advisors are fair but stringent in providing treatment authorization. A family practitioner
from San Diego expressed the feeling that advisors are "hamstrung by state regulations." Respondents in Los Angeles County were particularly critical of medical advisors, while those in Alameda, Contra Costa, Orange and San Diego counties appeared to be somewhat less critical. Almost two respondents in five from Orange County (38.9 percent) indicated that advisors are inconsistent in handling requests for authorization. In San Diego and in the Riverside-San Bernardino area, however, half of all respondents indicated that advisors are '"generally understanding." Although not shown in the tabular data, findings show that there is only a limited degree of association between physician opinions about medical advisors and medical specialty. However, physicians in strictly medical specialties (internal medicine, pediatrics, dermatology and so forth) tend to be somewhat more critical of medical advisors or of the system, than do physicians in most other specialties. An internist in Santa Clara County said: It is seldom that we are able to communicate with the medical advisor personally. Most requests are relayed to him (and his questions to me) through a clerk who has little medical knowledge.
A General Practitioner Sums It Up Summing up various concerns with the MediCal program experienced by physicians, especially those with considerable involvement in the program, one general practitioner from Alameda County made the following comments: I practice in a high Medi-Cal area, and I refuse three or four new Medi-Cal patients per week. I quit taking new patients when the total came to 25 percent of my practice. Since my expenses are about 50 percent of my receipts, I felt very uneasy about having half of my personal income dependent on Medi-Cal, to be reduced or deferred as they see fit. I would accept more Medi-Cal patients if I could feel that the program was dedicated to fair treatmen of both patient and doctors.
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