Plumas County residents are once again experiencing decision makers’ preference for larger urban communities when it comes to their health care. Last year, it was Eastern Plumas Health Care’s battle to keep their skilled nursing facilities (SNFs) open in the face of cuts that would unfairly affect small, rural communities. This year, the hit is being felt by the new Medi-Cal enrollees. In both cases, the promise of “access to care” seems hollow—and it points to a prejudice against our rural communities that sets a dangerous precedent.
Rural counties such as Plumas have recently been required to shift to Medi-Cal Managed Care (MMC). Managed Care is handled by two plans in Plumas County—Anthem Blue Cross and California Health and Wellness. The new plans have absorbed Healthy Families and Path to Health patients. This, along with the higher allowable income for enrollment, means an increase of two million MMC enrollees in California. The shift to managed care combined with the sheer number of enrollees is causing serious access issues for patients, especially in rural counties like Plumas.
Our local doctors are having trouble finding specialists for their patients who will take the new Medi-Cal plans. And, the specialists who do accept patients are often a long distance away. We are a two insurance provider county, as well, which means that a patient might expect to go to a specialist they’ve seen before under the old Medi-Cal only to be told that provider isn’t in their new network.
One EPHC patient in need of spine surgery was given a specialist appointment at USC in Los Angeles. This nine hour trip for a low income patient who needs spine surgery is about as mind boggling as the state’s assertions during last year’s skilled nursing battle. At that time, the state claimed there was “adequate access” to skilled nursing facilities for EPHC’s SNF residents should the facilities close. The facilities that the Department of Health Care Services (DHCS) paired EPHC with were as far away as Thousand Oaks, CA, also nine hours away.
In urban areas, however, adequate access is usually defined as 30 miles or 45 minutes maximum. This isn’t a small disparity. Rural areas are typically lower income than their urban counterparts. They have a higher unemployment rate, higher mortality rate, higher percentage of elderly residents…and the list goes on. They have fewer doctors per capita, and fewer specialists. In short, they need more, but they often get much less.
Legislation in California, not surprisingly, favors urban areas. Legislators want to get re-elected and they want to please the special interest groups that support them. Rural areas don’t have a lot of leverage—they don’t have huge numbers, lots of money, or influential lobbies. When it comes to rurals, we hope that those who make decisions affecting our lives will do the right thing, we try to embarrass them into doing the right thing, and when we can, we figure out a way to force them to do the right thing.
When it came to the skilled nursing fight, we pointed out that coupling rural counties that had a similar bed rate (dollar amount) might sound logical, but while it allowed the state to arrive at the desired conclusion—adequate access—it in fact was not logical. We cited a number of federal and state accepted standards (we used those set by the Center for Medicare/Medicaid Services and the Office of Statewide Health Planning and Development [OSHPD]) that showed their conclusions were unacceptable.
When these discrepancies were brought to the attention of certain people at the Department of Health Care Services there was, unbelievably, an open ear and a change of heart. But, rest assured it was a battle, and if we hadn’t fought it ourselves we would likely have lost our skilled nursing facilities.
Now, our Medi-Cal patients are suffering a similar state of unfairness and neglect. They are also facing greatly increased denials on medications they’re used to receiving under their previous plans. Further, independent pharmacists like Mike Kibble and Kevin Goss are taking such a huge hit in reduced reimbursement from the two Managed Medical providers, that they’re talking about the possibility of having to close their doors. That would leave one chain pharmacy, Rite Aid, in Quincy to serve the entire county. Again, imagine a patient who is ill and needs medication right away being faced with a drive of 40 – 50 minutes—that is if they have a car that can make the drive, and if they can afford the gas.
Kibble says the reimbursement rates they’re seeing—much lower than previous Medi-Cal rates—are “pennies over net procurement cost.” This doesn’t begin to pay for his overhead, staff salaries, and all the other costs of keeping a business open.
Moreover, Express Scripts, of Anthem Blue Cross, not only seems unbending on their rates, but they’ve also told Kibble that if he refuses to fill Medi-Cal prescriptions at their low rate, they’ll pull their other business from him. This leaves him with the choice to either “die now or slowly die on the vine,” he said. At this point, Kibble has chosen to keep filling Medi-Cal prescriptions and keep taking the hit.
Currently, the DHCS is soliciting input on access problems from the rural counties where the new Medi-Cal Managed Care system is seeing significant access problems. Eastern Plumas Health Care is involved in these sessions. What will happen, and if it will happen before Mike Kibble is forced to close his doors or before our patients suffer serious repercussions due to lack of true access to the specialty care they need, is uncertain.
In the SNF battle, EPHC presented its research to a department head that listened and told us exactly what to do to stop the reimbursement cuts. I’d like to think we were both smart and lucky. But, how often will we have to put up this kind of fight for the survival of our patients and our essential institutions? I think we’ve learned that when the rural counties band together, we’re more likely to be heard. We’ve learned that making sure we have well researched, factual information helps. But, none of these things guarantee that fairness will prevail; none of this ensures our survival.
How long will we have to fight for basic rights and services? Is there a way to get the state and even the country to see that rural America is an essential and iconic resource? Can we convince them that even people who don’t own lobbyists and aren’t connected to huge voting blocks deserve to be heard and cared for? Is there a way to get our elected officials to see that leaving the weak and the voiceless behind is simply, morally wrong and that a society can be judged by the way it cares for its most vulnerable members.
I don’t have the answers. For now, we’ll keep fighting and keep hoping we will be heard. But, what needs to occur is a sea change, a different way of thinking that allows that the values held for the many are also the values required by the few and that smaller, rural communities have the same right to essential health care that is granted to their urban counterparts.