Author: Chauntrece Washington

ITUP is Now Hiring!

Research Manager

Insure the Uninsured Project’s (ITUP) goal is to identify and promote new approaches to expand health care and coverage for the uninsured and to assure that those newly insured have good health outcomes. The Project’s focus is on developing connections among parties interested and able to make public and private reform happen. Our goals are accomplished through regional and statewide workgroups, an annual statewide conference, legislative briefings, reports, and network building.


Position: Research Manager
Location: 2444 Wilshire Blvd., Ste. 412, Santa Monica, CA 90403
Salary: D.O.E., Competitive with Benefits
Hours: Full Time

Job Description:

The Research Manager is an integral part of the ITUP team. This position provides research and analytical support to all team members.

Responsibilities include:

  • Researching and preparing reports on California health reform
  • Working with ITUP team members to plan meetings and events
  • Preparing and delivering presentations at workgroups, trainings and other ITUP events

Requirements include:

  • Masters in Public Health, Public Policy or equivalent
  • Excellent research, analytical and writing skills
  • Strong organizational, problem solving, communication and computer skills
  • Ability to work independently and cooperatively with colleagues
  • Proven ability to work under pressure, multitask and meet deadlines
  • Passion for health policy and reform efforts
  • Provide a resume and research-based writing sample on a health-related topic
  • Demonstrate strong communication and presentation skills
  • Valid drivers license and passport required

Applicants must provide a writing sample and 2 references.

Please send all documents to

Insure the Uninsured Project

2444 Wilshire Blvd., Suite 412, Santa Monica, CA 90403
Telephone: 310-828-0338, Fax: 310-828-0911

Behavioral and Physical Health Service Integration in California’s Safety Net: Six County Profiles

In the wake of the Affordable Care Act’s implementation, counties throughout the State continue to strive to meet the expectations set by the new law to better serve Medi-Cal beneficiaries. This includes providing more coordinated and integrated care that leads to improved service access and quality, better health outcomes, and reduced health costs. Roughly 16% of California adults have a mental illness, yet only around half receive treatment; 9% of the state’s residents have an SUD, and one in ten in that group receives treatment.[1] Therefore, providing better access to treatment that is integrated in a whole-person approach to care is especially important for newly insured populations that may disproportionately suffer with mental illness and/or co-occurring conditions (such as people struggling with homelessness or involved in the criminal justice system).

While all counties have responsibility for specialty mental health services, and most operate Drug Medi-Cal programs, each county is unique in how it administers and provides safety net physical and behavioral health services. This report details how six innovative counties have integrated behavioral and physical health services to better meet the needs of their residents. The profiled counties include San Mateo, Riverside, Los Angeles, San Diego, Shasta, and Santa Cruz Counties. All counties have some mix of directly operated and contracted specialty mental health service providers, yet the counties differ in whether or not they have directly operated medical delivery systems, the type of managed care models used, and how their managed care plans organize their mild to moderate mental health benefits. Moreover, each county has key elements of success that set them apart from one another.

San Mateo. The very strong relationship between the San Mateo County delivery systems and the local Medi-Cal managed care plan, Health Plan of San Mateo, has spurred many of the advances in San Mateo County. Moreover, San Mateo has a COHS model of Medi-Cal managed care with one local health plan and strong county-operated physical and mental health delivery systems that enable collaboration with fewer and more consolidated administrative entities. The close relationship between the delivery systems includes advanced data sharing capabilities that greatly promote integration, unified treatment planning, and evaluation of clinical outcomes and the overall cost of care across a broad range of Medi-Cal benefits. San Mateo participants also attributed the success of their pilots and innovations to the financial support and the strong and innovative leadership of both the County and HSPM.

Riverside. Riverside County’s integration efforts are a product of strong leadership of both County physical and behavioral health administrators and the local initiative Medi-Cal managed care plan, Inland Empire Health Plan (IEHP). Riverside is able to leverage its large County-operated heath care delivery systems in its integration efforts by co-locating staff to create interdisciplinary teams in both primary care and mental health clinics. Moreover, IEHP demonstrates unusual capacity to organize and deliver Medi-Cal behavioral health services by directly contracting its provider network, which includes County facilities, and adding wrap-around services not included in the Medi-Cal benefits package. IEHP additionally commits financial resources to integrating and co-locating services in both primary care and behavioral health facilities, as well as across administrative entities.

Los Angeles. Los Angeles County benefits from both strong financial resources and large County-operated and private safety net provider networks, as well as a commitment among County health administrators and the local initiative health plan, L.A. Care Health Plan, to innovative service integration models. In fact, Los Angeles County’s integration efforts extend beyond physical and behavioral health services to include social services, housing, and public safety. County administrators’ consensus to move toward integration has driven their efforts to co-locate and integrate services across its large networks of County-operated facilities. Moreover, the county’s strong community clinic network, the Community Clinic Association of Los Angeles County, contributes meaningfully to these efforts by participating in the creation of Health Neighborhoods and co-locating primary care practitioners in County mental health facilities where possible. While the commitment to and the resources for service integration are substantial, the major task ahead is to bring these efforts to scale across the very large delivery systems that serve the nation’s most populous county and its enormous diversity of residents.

San Diego. San Diego stakeholders rely on a strong planning body, the Healthy San Diego Behavioral Health Workgroup, in which health plans, County representatives, hospitals, advocates, and community clinics meet to identify challenges and responsibilities related to behavioral health services. The role of this planning space is particularly important for San Diego stakeholders because the county’s geographic managed care model of Medi-Cal managed care involves five plans, which can make coordination efforts a heavier lift with the greater number of administrative entities. Moreover, the County has a smaller directly operated health care delivery system for its size, which also amplifies the challenge of coordinating efforts across a larger number of providers.

Another central component of successful integration efforts in San Diego County was the robust partnership between the County and the community clinics. These stakeholders created regional triads of administrators of physical health, behavioral health, and SUD service facilities to align their services and create interdisciplinary learning communities. Clinics and the County also actively collaborate to skillfully transition clients moving from specialty mental heath services to those provided in community clinics.

Shasta. Shasta has the advantages of very strong collaborative relationships among its stakeholders. The Shasta Health Assessment and Redesign Collaborative serves as a central planning workgroup, and the reflex to coordinate and integrate services is strong in this region of California. At the same time, Shasta has fewer resources than many of the larger counties, both with regard to County financing and its provider networks. County administrators and Shasta’s provider networks have been able to pioneer integration efforts in this environment by creating innovative contracts and financing arrangements. These partnerships have integrated services through co-locations that allow for the creation of interdisciplinary care teams. Further, a strong COHS-model Medi-Cal managed care plan, Partnership Health Plan, extends resources and technical expertise to aid provider recruitment and care coordination. While Shasta’s stakeholders continually struggle with provider supply, all stakeholders are committed to better use of technology to respond to this increasingly pressing issue as they integrate Medi-Cal services.

Santa Cruz. Santa Cruz County’s efforts to integrate have revolved around the special needs of their communities and the resources available to them. Santa Cruz stakeholders have come together across an unusually broad range of stakeholders that spanned across physical health, behavioral health, social services, housing and criminal justice to address the needs of people struggling with homelessness. Moreover, the lack of large public health care delivery systems motivated Santa Cruz stakeholders to collaborate and to pool or share resources. The City of Santa Cruz partnered with the County to provide funding for innovative interdisciplinary programs that relied on many non-profit service providers to assist some of the county’s most vulnerable residents. Perhaps most strikingly, the broad coalition of service providers effectively tackled a complex social problem and made a tangible impact on residents’ overall quality of life.

In summary, stakeholders in every county communicated the critical contributions of durable local leadership and an interdisciplinary planning workgroup, formal or informal. Almost all counties’ stakeholder groups also identified the importance of either a funding source or flexibility with funding to put their ideas into practice. On the provider level, many of the participants reported the necessity of bridging provider cultures in the process of building interdisciplinary teams.

Virtually all participants cited the importance of the expanded Medi-Cal mental health and SUD benefits that were newly implemented in 2014. Many stakeholders expressed dissatisfaction with the division of responsibilities between Medi-Cal managed care plans and county specialty mental health plans for mental health benefits. However, the need for these entities and provider networks to collaborate to develop MOUs to navigate the bifurcation of responsibility was important to building agreements and stronger communication across entities.

Data exchange between providers and delivery systems remains one of the more primitive capabilities that the administrators and providers were able to use, but it was cited universally as very pivotal to integration efforts. In fact, expanding the reach of telemedicine and e-medicine was a central piece of some counties’ integration efforts.

[1] California Mental Health and Substance Use System Needs Assessment. 2012. Technical Assistance Collaborative. Available at: %20Assessment%203%201%2012.pdf

To read the whole report click here:

County Behavioral Health Profiles



Senator Lara’s bill (SB 4) Suspended in Appropriations

As of May 4, 2015, Senator Lara’s bill (SB 4) to expand insurance to undocumented Californians has been placed on hold. This decision comes in the wake of a fiscal analysis of SB 4. According to a Senate analyst, estimated coverage costs for undocumented individuals range from $280 million to $740 million annually. California’s Medicaid program has expanded greatly in response to full implementation of the Affordable Care Act. Therefore, if SB 4 were to become signed in to law, the state would need to substantially increase its financial commitment to the Medi-Cal program.


Also, pending court decision on President Obama’s executive initiative to expand the Deferred Action for Childhood Arrivals (DACA) program and create the Deferred Action for Parental Accountability (DAPA) program, has the potential to impact Medi-Cal dollars. California has taken the unique position to offer Medi-Cal eligibility to individuals with DACA status that meet income requirements. If President Obama’s executive order were granted, the State would be on the hook financially. Consequently, cost continues to be a hurdle for the legislation.


SB 4 is Senator Lara’s second attempt to extend coverage for undocumented individuals, and just like its successor, there were funding concerns. While the cost of coverage for the undocumented remains a hurdle, ITUP encourages stakeholder to work towards a consensus that could provide truly universal coverage.

March Covered California Board Meeting

Now that California’s second open enrollment has closed, it’s time to continue thinking about the future. During Covered California’s latest board meeting, there was a lot of discussion about the 2016 plan year and beyond. Below are the details from the March 5th board meeting.

New Appointees

It was announced that Governor Brown named two new board members to replace the vacancies that will be left by Kim Belshe and Susan Kennedy. The new appointees are Genoveva Islas and Marty Morgenstern.

The board approved Karen Ruiz, the previous project director of CalHEERS, as the new Chief Technology Officer for Covered California.

2015 Open Enrollment Update

Although, we were able to cover many Californians’ during the first open enrollment, it is exciting to note that even more people are getting enrolled.


Retention rates were more positive than forecasted. It was predicted that 2.5% of consumers would leave their Covered CA plan each month. In actuality, 1.5% of consumers left, largely due to transitions into employer-sponsored insurance, Medicaid, and Medicare. Other enrollment updates included effectuation rates and special enrollment numbers. Covered CA forecast that 85% of consumers would effectuate (pay their monthly premiums), only 80% of consumers effectuated. This matched the national average. Additionally, fewer individuals utilized special enrollment periods than anticipated. There were a smaller number of individuals that had job-based conversions and transitioned out of Medi-Cal. One reason given for low Medi-Cal transitions was the lack of redeterminations at the county level. This caused the base of those up for renewals to be smaller. Yet, for those up for renewals, they renewed at a strong rate.


In January, Covered California sent out 1095A forms, which detailed the tax credit subsidies received, to individuals that received premium assistance in 2014. Approximately 90% of forms reached the intended person and held accurate information. For individuals who did not receive forms or received forms with inaccurate information, about 100,000 persons, Covered California followed up and sent corrective forms.

Clarification was also given regarding a new special enrollment opportunity. For consumers unaware that they may face a penalty for being uninsured in 2014 or those that learned that they might face a penalty in 2015, a limited time Special Enrollment period was introduced. Consumers have until April 30th to self-attest that they were not informed that they were at risk for a tax penalty. It was made clear that this is not an extension to open enrollment.

Recertification and New Entrants

Policies for 2016 certification and recertification of SHOP and dental plans were approved in January, but clean up items were discussed. Announced items included:

  • For the 2016 plan year, plans that were grandfathered will need to become ACA compliant
  • New plans will have the opportunity to become Qualified Health Plans (QHPs) effective October 15, 2015
  • Current QHPs will also be given the opportunity to offer new products, effective October 15, 2015
  • There will be no new benefit design for dental plans

Standardized Benefit Design

Although a standardized benefit design for 2016 was adopted during the January board meeting, several proposals were brought before the board.


In previous plan years, Emergency Room (ER) cost sharing was mixed with both coinsurance and co-pay plans. It was stated that the facility fee was set at a flat rate (co-pay) and the physician fee at a coinsurance fee. The mismatch of cost sharing fees makes it difficult for plans to offer alternate cost sharing structures. As a result, Covered California staff proposed a flat co-pay for ER physicians in silver plans.

Specialty Drugs

Due to the expensive drugs coming down the pipeline, that range from $30,000 to $100,00, Covered California is interested in identifying how hefty price tags on future drugs will impact medication adherence, medical costs long term, and long term affordability. To help alleviate the financial burden of specialty drugs on individuals with ongoing chronic needs, there were 4 proposed actions.

  • Require more transparency about formulary information and increase the accessibility of information for both consumers and advocates
  • Develop standardized definitions for formulary tiers
  • Establish requirements that prescriptions for chronic conditions like HIV are available outside of tier 4, which has the highest cost sharing
  • Consider placing a per script per month cap on specialty drugs. There was a request placed for health plans to analyze whether they have the ability to administer this type of product and how a cap would impact actuarial value. Based on received information from plans, Covered California staff will bring a recommendation forward on how to implement a cap during the May board meeting.

The hope is to guide consumers to the most appropriate and cost effective drugs, support premium affordability, and preserve the health plans’ ability to maximize savings and control drug costs.

Enrollment Assistance

To help successfully transition enrollment workers from the In Person Assistance program to the non-compensated Certified Application Counselor (CAC) program, Covered California will continue paying assisters the $58 per application fee. This will allow assisters to continue their work, and help individuals that qualify for the new special enrollment category. Payments will end June 30, 2015.

Other Things We Learned

  • The service center handled 1.3 million calls. There was a better and faster response rate, 50% of calls were answered in less than 30 seconds. Also, there was only 10% abandonment (consumers that did not stay on the line) compared to last year’s 50%.
  • More individuals signed up for coverage with assistance, especially in Asian communities
  • More consumers chose Kaiser plans during this open enrollment
  • There was a slight increase in consumers that chose bronze plans
  • In May, there will be a draft report on surveyed consumers about their experience and understanding of Covered California. Information will not only identify the types of programs chosen, but will also describe consumer knowledge of their choices.
  • Covered California will transition from federal funding to sustainable funds in 2017. A sustainability plan has been developed, which would create a 3-month reserve. Action on the sustainability plan will be taken at the next meeting.

The next meeting is planned for Thursday, April 16, 2015. As always, the meeting materials are available on the HBEX website.


Solo and Small Group Physician Practices in California (UPDATED)

Solo and small group (fewer than 10) physician practices are an important piece in California’s healthcare landscape. They serve as access points for consumers to receive healthcare services, emphasize relationship-based continuity of care and serve the geographically and socio-economically underserved. More specifically, solo and small group physicians commonly serve ethnically diverse communities, presenting patients with culturally sensitive and competent care. In terms of access to care, nearly 70% of all ambulatory visits are to medical practices with five or fewer physicians and nearly one-third of U.S. physicians practice in solo and two-physician practices. These statistics indicate the high volume of individuals that utilize solo and small group physician practices for their healthcare needs. Also, the type of care provided by private physician practices is built on patient-provider relationships that develop as a result of ongoing care provided by a single physician. The physician may be more informed of a patient’s family life and general living environment. Recent studies have illustrated that solo and small group practitioners have lower re-hospitalization rates than larger practices; the point being that this aspect of care provided by private physicians may lead to better patient outcomes. Finally, solo and small group practices serve a large portion of underserved Californians. For example, 60% of Medi-Cal consumers receive care from solo and small group practices and between 49% and 85% of primary care physicians participate in Medi-Cal (depending on the region). Additionally, approximately 15% of rural Medi-Cal patients seek care from private physicians or physician groups. The availability of solo and small group physicians to Medi-Cal recipients has a large impact and must not be overlooked. It is these characteristics, as well as access, continuity of care, and a commitment to the underserved that make solo and small group practices a vital part of California’s healthcare mosaic.

However, it has become increasingly difficult for solo and small group physicians to practice medicine due to financial barriers, administrative demands and lack of adequate resources. The difficulties associated with opening and maintaining a practice has led to the downward trend of solo and small group private physician practices. Responses from graduating medical students show only 1.1% of graduates are interested in solo practice medicine. Also, only 1% of physician job searches were for solo practice placements. This data demonstrates the waning interest in solo physician practice over the years. This trend will have broad implications for access to care for many individuals.

As the health system continues to evolve, so does the private practice model. Physicians are joining larger medical practices, closing their practice to specific insurance types (e.g. Medi-Cal), experimenting with new payment models, and retiring. The issues that solo and small group physicians face must be addressed in order for these practices to not only remain a feasible option in California’s healthcare system, but also a source of care that is accessible and affordable for the most vulnerable individuals. This report will consist of three parts that identify and discuss challenges for solo and small group practices that limit their ability to be seen as viable practice models in the current health care landscape. Part I will provide an overview of California’s physician practice landscape. In part II, findings from stakeholder interviews will be covered, revealing the challenges of solo and small group physician practices. Part III will present ITUP’s recommendations for multilevel approaches to support the continual existence of the solo and small group practice model


Download the all three parts here:

Solo and Small Group Practices (part 1)

Solo and Small Group Practices (part 2)

Solo and Small Group Practices (part 3)



The Commonwealth of Massachusetts’ new Medicaid waiver

Recently Massachusetts received approval from CMS to extend their §1115 Medicaid waiver demonstration project (also known as MassHealth). Through a Medicaid waiver, the state aims to continue creating delivery system transformations and to better align the Commonwealth’s programs with the Affordable Care Act. But more on that later. First lets take a look at all the promising health reforms Massachusetts has achieved up to this point.

A brief timeline of events:


  • Created the Uncompensated Care Pool (also known as “Free Care” Pool). Funds from the pool were used to pay hospitals and community health centers for all uncompensated care to low-income residents and emergency care for non-residents.


  • Enacted a “play or pay” mandate for employers with 25 or more employees. Although enacted, it was never implemented.


  • Introduced insurance market reforms that included guaranteed issue and modified community ratings in the small group and individuals markets. Plans were also required to offer standard benefit packages.


  • Initial implementation of MassHealth. The demonstration expanded Medicaid income eligibility for pregnant women, parents, adult caretakers, infants, children, and individuals with disabilities. Medicaid coverage was also extended to certain non-categorically eligible populations (e.g. persons with HIV). Certain beneficiaries were required to enroll in managed care plans to generate cost savings. Additionally, the Insurance Partnership program, which offers premium subsidies to qualifying small business employers and their low-income employees, was implemented.


  • The Safety Net Care Pool (SNCP) was created through the 2005 MassHealth waiver renewal (enacted in 2006).


  • Governor Mitt Romney signed into law a new health insurance reform. Some key components include:
    • Nearly universal health insurance for all residents
    • Implementation of an individual mandate
    • Merger of the individual and small group market into a single risk pool
    • Expanded Medicaid coverage to adults without minor children living at home
    • Creation of a health insurance exchange (Commonwealth Connector or The Connector)
    • Insurance market reforms: coverage and affordability standards

Does any of this look familiar? Well it should.

The 2006 health reform law in Massachusetts, affectionately referred to as Romneycare, was used as a model for Obamacare. This means that the Commonwealth was strategically placed to implement key provisions of the Affordable Care Act. Not only were most residents insured, but there was also a strong safety net system already in place to support the newly insured and uninsured populations.

Even more importantly, this timeline shows that Massachusetts has been a national leader in health reform time and time again. So it is only fitting that we pay attention to how they have decided to maintain their ‘leader’ status on this next go around.

Massachusetts’ demonstration waiver was approved for renewal on October 30, 2014 for $41.4 billion. It includes $20 billion for delivery system transformations, with about $230 million a year (for 3 years) dedicated to safety net hospitals. The new extension period will last through June 30, 2019, giving the Commonwealth 5 years to really implement delivery system reforms and see some positive (or negative) gains.

Governor Deval Patrick proposes to continue to improve Massachusetts’ ability to provide affordable coverage and improve the quality of care through a number of ways. The approved waiver extension does the following:

  • Continues streamlined redeterminations for families enrolled in the Supplemental Nutrition Assistance Program (SNAP) and extends express lane eligibility to adults receiving Medicaid and SNAP benefits
  • Continues pilot programs for pediatric asthma and early intervention services for children with autism
  • Gives authorization to continue the use of state subsidies to provide premium assistance through the Connector for individuals with incomes up to 300% of the Federal Poverty Level (FPL).
  • Develops a Primary Care Payment Reform Initiative (PCPRI) and Accountable Care Organization (ACO) model.
    • Gives the authority to set shared savings/risk targets for providers and to make shared savings payments under an alternative payment structure.
  • Continues delivery system transformations that include:
    • Improved integrated and coordinated care for individuals under the age of 65 that qualify for Medi-Medi through a duals demonstration (known as One Care).
    • Integration of behavioral health into primary care
    • Expansion of SNCP to help safety net hospitals develop payment reforms and move from a fee-for-service model to a disease prevention and health maintenance approach

This seems like a substantial undertaking. Not only is Massachusetts attempting to sustain near universal coverage, but contain healthcare spending as well. Alternate payment models are a good idea, but always tough to execute. I for one will be interested to see how Massachusetts fares on these ambitious value purchasing measures.

Good luck to Massachusetts, as I’m sure all eyes are watching what they will do next.


Will Local Hospitals Survive Cuts to Funding for Indigent Care Programs?

Since the beginning of 2013, twenty-four rural hospitals have closed across the country, and many observers believe that more closures will occur. They blame this on the Affordable Care Act (ACA). The ACA aims to extend coverage to the most vulnerable populations by offering states the option to expand their Medicaid programs. If more individuals are covered through Medicaid and Covered California (the Exchange), costs for uncompensated care will decrease.

Consequently, the ACA authorizes cuts to funding for indigent care programs. These statutory cuts include funding through Disproportionate Share Hospital (DSH) payments. Federal administrative waivers that pay for uncompensated care such as Safety Net Care Pool and Delivery System Reform Incentive Pool may not be renewed when they expire. Since Medicaid expansion is optional due to the decisions of the Supreme Court and some state’s policymakers, many Southern and some Rocky Mountain states have opted not to expand their program. In these states, rural hospitals that rely heavily on federal support are predicted to have increased financial burdens and more closures.

For example, Texas’ Linden Hospital was forced to close earlier this year due to a steady decline in patients and reductions in Medicare and Medicaid payments.  In a recent article describing the financial struggle of Linden Hospital, a former patient reported that the next closest hospital is 15 miles away. For individuals without a means to travel large distances, this presents a barrier to accessing care. Many times rural hospitals are the only source of care that a community relies on. If federal cuts and the opposition to ACA’s Medicaid expansion continue, hospitals already having trouble filling beds will fold. Without sufficient financial viability and lack of the newly authorized federal funds, the numbers do not balance. Because Texas decided not to expand their Medicaid program, and the prospective federal cuts to indigent care funds that hospitals rely on; rural hospital closures could leave a gap in care for community residents. Parents with dependent children with income between 15% and 100% of the federally poverty level do not qualify for Medicaid or health exchange plans in Texas. Adults without minor children and incomes up to 100% of FPL do not qualify at all for Texas’ Medicaid program. This will leave the most vulnerable individuals, typically the uninsured, without access to their only source of care.

Even for states that expand their Medicaid program, it is likely that rural hospitals will need to adjust their delivery systems due to the ACA to put a greater emphasis on outpatient care. This has been the case for a few rural hospitals in California. With the implementation of Medicaid expansion, health coverage has increased and inpatient volume has decreased. Newly insured individuals now have more health care options. Individuals living in geographically distant and remote areas have the option to receive care at Federally Qualified Health Centers (FQHCs), local physician offices and other community clinics. The transition of patients from hospital settings to community providers may negatively impact some hospitals’ revenue growth and operating margins.

In California, state, local and federal funds to support indigent care have diminished as the ACA expansion funds have increased; we think that the ratio of expansion to reductions is roughly ten to one. Since the ACA has reduced the number of uninsured, the amount of Realignment funds that counties receive for healthcare has been cut and the federal waiver funding for county Low Income Health Programs (LIHP) have been discontinued. In combination with the reduction in inpatient volume, the reduction in government assistance strongly impacts the ability of those hospitals that continue treating those who remain uninsured and lose the newly insured patients and revenues to other local competitors.

The ACA has succeeded in many ways. More individuals are insured and seeking care through their community providers. But, for those who remain uninsured, if local hospitals close their doors, where will they continue to seek care?

Along with other obstacles rural health systems face, like provider shortages, changes in patient distribution among facilities and reductions in government assistance add additional challenges to an already overburdened system. To improve the health of everyone, not just those insured, continual investment in the safety net is vital as providers adjust to the evolving health care system.

Are Physicians Willing to Accept Medi-Cal Patients?

Looking at California’s remarkable Medi-Cal enrollment numbers, the million-dollar question is whether there will be enough physicians available to meet increased demands. Traditionally, physician participation in the Medi-Cal program, especially among non-primary care physicians, is low. One arguable reason for low participation is low reimbursement rates. Physicians may be unable to take on new Medi-Cal patients and keep their practice afloat. However, with the transition of individuals from Healthy Families and Low Income Health Programs (LIHPs), along with Medicaid Expansion, the total number of Medi-Cal beneficiaries has reached an estimated 11.5 million (up from 9.4 million, 2013-2014). This represents a significant increase of beneficiaries, demonstrating the importance of the current available workforce.

To provide insight on this issue, the California Healthcare Foundation (CHF) recently released a report that assessed physician participation in the Medi-Cal program. Findings in the report are based on phone surveys of physicians conducted in 2011 and 2013. Additionally, findings are reported based on several categories, such as acceptance of Medi-Cal versus other insurance types, and Medi-Cal participation by major specialty.

Here are some key findings from the report:

  • In 2013, 69% of California physicians accepted Medi-Cal patients
  • California physicians are less likely to accept new Medi-Cal beneficiaries (62%) than individuals with Medicare (75%) or private insurance (79%)
  • Community clinics (92%) are more likely to care for Medi-Cal beneficiaries than small group practices (76%) and private doctors (54%)
  • OBGYNs (76%) and Pediatricians (75%) are more likely to serve Medi-Cal beneficiaries than general practitioners (64%) and psychiatrists (47%)

Between 2011 and 2013, physicians with any Medi-Cal patients increased from 64% to 69%. The percentage of physicians with 1% to 9% Medi-Cal patients increased significantly. Among primary care physicians, the percentage of Medi-Cal patients increased from 35% to 42%. For non-primary care physicians, Medi-Cal patients increased from 32% to 38%. Although more physicians are participating in Medi-Cal, among all participating physicians, on average, less than 30% of their patients are enrollees. Approximately 40% of physicians carry the burden of providing 80% of all Medi-Cal visits. Thus, despite the increase in physicians participating in Medi-Cal, an access problem likely still exists in certain areas due to unequal distribution of participating providers across the communities that need them.

Considering the increase of Medi-Cal enrollees, low acceptance of Medi-Cal patients is cause for concern. If new beneficiaries are unable to gain timely access to care in their communities, they are more likely to utilize emergency departments. Although an easy and accessible resource, services rendered in emergency departments are episodic in nature and much more costly. When the goal is to move towards a healthcare system that emphasizes cost containment and preventive care, increased ED use is a step backwards.

To improve the overall health of Californians, vulnerable populations must be a priority because of the difficulty that many Medi-Cal beneficiaries may experience when attempting to access needed services. While the issue may be complex, the data show us that we need to continue thinking through ways to increase the number of physicians who are willing to take on larger caseloads of Medi-Cal beneficiaries.

Creative Innovations in Oral Health Care

During a time when many in health policy stakeholders are emphasizing health integration and whole-person care, it is surprising that dental care is not more often a part of this discussion. There has been an overwhelming amount of chatter regarding workforce shortages and how to make care accessible to more consumers. However, many (not all) of these conversations revolve around primary care physician shortages, how we can get more doctors into the supply pipeline, and augmenting our existing workforce by expanding scope of practice laws for nurse practitioners and physician assistants. This same fire and passion seems to be lacking for dental providers. But let’s face it. Dental care is not as sexy to some people as other healthcare topics might be.

In any case, dental care workforce challenges should be acknowledged. Data collected by the Office of Statewide Health Planning and Development (OSHPD) for 2013, shows a lack of dentists in nearly every county except Los Angeles, Orange, San Diego, the Inland Empire, and a few northern counties like Contra Costa and Santa Clara.

Picture 4

Even without social and economic barriers, many Californians simply do not have access to a dentist because of where they live. To help reduce shortage issues, policymakers are considering expanded roles for oral health professionals. The adoption of dental therapists, midlevel professionals similar to physician assistants, is slowly gaining approval in most states. Currently, dental therapists are allowed to practice in Alaska, Minnesota, and Maine.

California has not adopted the use of dental therapists. Instead, a few cities have implemented teledentistry as part of the Virtual Dental Home Demonstration Project (VDH). VDH is authorized under OSHPD’s Health Workforce Pilots Project (HWPP) to provide dental care to vulnerable adults and children. In the pilot, dental hygienists and dental assistants travel to head start sites, schools, and nursing homes to examine and collect dental information. A secure email system then transmits collected information to a dentist offsite, and the dentist creates a treatment plan for the onsite provider to follow. Onsite providers decide which x-rays to take and are allowed to place temporary fillings. If more extensive work is needed, patients are referred to a dentist. Onsite visits relieve parents and children from the burden of a typical office visit. Parents do not need to take time off work, and children are provided care in familiar and comfortable surroundings. Additionally, adults and children are given preventive care as well as services to temporarily prevent further oral health deterioration.

OSHPD’s HWPP program was designed to allow providers the ability to demonstrate the effectiveness of expanded professional roles in advance of any changes to scope of practice laws. And, in fact, VDH has successfully demonstrated the need for oral health care and education, and the ability for dental hygienists and dental assistants to work under the virtual supervision of dentist when conducting preventive procedures. Given these successful outcomes, this project should continue.

Assembly Bill 1174, introduced by Senator Bocanegra and Senator Logue, would allow statewide implementation of VDH, expand roles for dental hygienists and dental assistants, and make teledentistry reimbursable under the Medi-Cal program. AB 1174 is currently before the Senate Committee on Appropriations, and a hearing is set for August 4th.

Because there is a proven linkage between oral health and medical conditions like heart disease, we should rally behind innovations that seek to improve oral health for vulnerable populations. That is something to smile about!

State Budget Funds New Primary Care Residencies

In the recently approved state budget, Governor Jerry Brown and the Legislature took an important step to help recruit and retain the primary care workforce in underserved areas. As mentioned in a previous blog, the state budget plan appropriates $136.7 billion to Health and Human Services. Of the appropriated funds, approximately $8.8 million will go to the Office of Statewide Health Planning and Development (OSHPD) to expand the Song-Brown Program. For those unfamiliar with Song-Brown, it provides funding in the form of grants to accredited family physician residency programs, physician assistant programs, family nurse practitioner programs, and registered nurse programs. Funding can be used to support faculty training, resident stipends, and other activities that provide the opportunity to gain experience in primary care settings.

Under the budget plan, there are two proposals to augment the existing program. The first proposal will help Song-Brown expand to include additional primary care specialties. This proposal provides $2.84 million per year for three years to fund approximately 25 grants to internal medicine, obstetrics and gynecology (OBGYN), and pediatrics residency programs (for old and new residency slots). Grants will cover 159 primary care residents in underserved areas. The second proposal grants one-time funding of $4 million to support new residency slots. Preference will be given to California-trained physicians.

Additional residency slots are critical. There is an ongoing debate regarding the existence of a primary care workforce shortage in the U.S. Many argue that there are fewer and fewer doctors interested in primary care specialties, while others believe there is not a scarcity but a misdistribution of providers. Throughout California, especially in rural communities, stakeholders regularly express frustration about difficulty recruiting providers for their health centers and community clinics. Also, areas with high caseloads of Medi-Cal beneficiaries tend to have a dearth of providers. Medi-Cal providers receive lower payments than physicians who only accept other types of insurance, and certain areas and specialties are simply less desirable for medical students with substantial loan debt.

Workforce issues are also a cause for concern with approximately 4.1 million individuals now enrolled in coverage thanks to the ACA. Despite being enrolled in coverage, if a shortage truly exists, consumers could have real challenges accessing care. Furthermore, there has been quite a bit of talk about access issues potentially leading to enrollee retention issues. If consumers find it difficult to see providers, it is unlikely that they will continue to pay premiums. After all, who wants to continue making monthly payments, which may be very large relative to monthly incomes, if services are so difficult to obtain?


This is where the new Song-Brown residency slots become a factor. More residency slots dedicated to underserved areas, means more bodies (at least for now) in areas that need them most. Song-Brown grants also represent a financial incentive for medical students who are fearful of accumulated debt. So although these residency slots won’t single-handedly reverse workforce issues, they are a win for residency programs that are constantly seeking ways to fund additional primary care positions.


To learn more about workforce issues, click here.