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Many Californians get new benefit — advance care planning


F0r Kaiser Health News


Millions of Californians are newly eligible for a healthcare benefit that could determine the treatment they receive in their final days — and most don’t know it.

Medi-Cal, which covers more than 13 million Californians, and Medicare, with more than 5 million California enrollees, now pay for “advance care planning” discussions with doctors.

Advance care planning isn’t about long-term-care options, such as nursing homes or assisted living.

It’s about “your wishes for your care if you are not able to speak for yourself,” said Helen McNeal, executive director of the California State University Institute for Palliative Care.

“If you’re incapacitated, if you need someone to speak for you, who do you want to speak for you? And what would be your medical wishes?” she said.

If, for instance, you have a stroke that leaves you unconscious and unable to communicate, with little hope for improvement, would you want to be kept alive with a feeding tube and or ventilator?

“These decisions may have consequences for the quality of life you have for the rest of your life. They may also have consequences for whether you live or die,” McNeal said.

In other words, they’re important. But many doctors and patients don’t yet realize that talking about these decisions — and possibly putting them into writing — is a covered benefit.

Starting in October, Medi-Cal — the state’s version of the federal Medicaid program for low-income residents — began covering advance care planning discussions between doctors (or other qualified providers) and patients (or a family member), said Tony Cava, spokesman for the state Department of Health Care Services, which administers Medi-Cal.

Any Medi-Cal recipient can use the coverage regardless of age, he said. Doctors can bill for the conversation twice a year per patient — plus an additional 30 minutes for one of the conversations — before they have to seek authorization for more coverage.

Medicare, the federal health insurance program for people 65 and older, and for people younger than 65 who have certain disabilities, started covering the discussions on Jan. 1. Medicare does not limit the number of discussions per patient each year.

Some private insurance plans cover these discussions and some don’t, McNeal said. Check with your plan.

Both Medicare and Medi-Cal will cover the conversations even if patients don’t end up completing an “advance care directive” as a result. That’s a document that formalizes your wishes, which should be shared with your family and doctor.

McNeal believes that anyone over 18 should have this discussion and complete an advance directive.

But don’t expect your doctor to initiate the conversation.

“Many physicians may not be very comfortable having this conversation,” said Richard Thorp, M.D., president of the Paradise Medical Group near Chico, and past president of the California Medical Association, which represents the state’s doctors.

A poll of more than 700 doctors, released in April, found that nearly half of them feel unsure some or much of the time about what to say when discussing end-of-life care with patients. (The poll was commissioned in part by the California Health Care Foundation. California Healthline is an editorially independent publication of the California Health Care Foundation.)

Thorp’s patients are mostly older, so he incorporates advance care planning into their annual Medicare Wellness exams. Medicare reimburses him about $86 for the initial 30-minute discussion, and about $75 for each additional 30 minutes, he said.

“There’s an art to having the discussion,” he said. “There’s an art to recognizing when people are uncomfortable.”

McNeal’s institute, in partnership with the Coalition for Compassionate Care of California, offers online training for doctors about advance care planning. One course specifically focuses on how to have an effective conversation with patients.

Because many doctors don’t know about this benefit — or may feel uncomfortable broaching the topic — most people should start by having a conversation with family and loved ones, suggested Mark Beach, an AARP spokesman based in Sacramento.

After your discussion, write down your wishes, he said.

“It’s difficult to discuss, but when you’ve done it, it’s a comfort,” Beach said. “Not only will your wishes be followed, but your loved ones will know what to do.”

A variety of forms and templates are available to consumers. Thorp sometimes uses what’s called a “POLST” form, which is a medical order that must be completed and signed by a health care professional.

It is typically for seriously ill or frail patients, McNeal said, whereas an advance care directive is a legal document for people of any age or condition.

McNeal recommends the “Five Wishes” form, which can be personalized and is available online for $5 at Other options for advance directives can be found at or through AARP. (A lawyer can help you prepare an advance directive, but you usually don’t need an attorney to get it done.)

After you have filled out your advance care directive, take it to your doctor and tell her you want to talk with her about it, McNeal said. Don’t forget to give your doctor a copy.

“The role of the physician is really to provide information, not to persuade one way or the other,” Beach said.

Thorp explains to his patients what it means to be intubated, fed artificially and kept on life-support.

Most are open to the discussion, he said, and their responses are mixed. Some older or sicker patients tell him they don’t want any extraordinary measures if they’re incapacitated. Others, who are younger and healthier, say they would probably want medical intervention if they might have a chance to thrive afterward.

“Most people don’t want to be kept on life-support indefinitely. They really don’t want that,” Thorp said. “They want to live a productive life.”


Calif. to expand coverage to illegal alien children


Border crossing between San Diego, Calif., and Tijuana, Mexico.

Medi-Cal, California’s Medicaid program, will expand coverage to at least 170,000 children, mostly Hispanic, who are in the state, and thus nation, illegally.

The Sacramento Bee reported that “They’ll gain access to not just emergency coverage but also dental care, checkups, mental health treatment and other vital services following an unprecedented Medi-Cal expansion that provides full coverage to all low-income children in the state, regardless of immigration status.”

The expansion will probably mean lots more patients at the state’s Federal Qualified Health Centers and hospital emergency rooms.

The Bee reported that the expansion “is exclusively state-funded and is expected to cost the state Department of Health Care Services about $132 million annually. A 2015 study from the Public Policy Institute of California concluded that about half of the state’s undocumented immigrants have incomes low enough to qualify for Medi-Cal.”
Few disinterested observers believe that the $132 million figure is plausible. It will almost certainly cost much more.

Health centers struggle to treat many new patients

By SARAH VARNEY, for Kaiser Health News

See this link for the accompanying PBS video.


The Affordable Care Act unleashed a building boom of community health centers across the country. At a cost of $11 billion, more than 950 health centers have opened and thousands have expanded or modernized.

In San Diego, new clinics have popped up on school campuses and busy street corners. Cramped storefront clinics have been replaced with gleaming, three-story medical centers with family medicine, radiology and physical therapy on site. They are outfitted to care for new immigrants in dozens of languages from Spanish to Somali.

The community health centers are the country’s largest primary-care system for low-income patients, now working to absorb a tsunami of new Medicaid enrollees.

At age 58, after several worrisome decades without health insurance, Lori Simpson is finally getting treatment for her dangerously high blood pressure, a serious thyroid disorder and, after years of double vision that had made it difficult for her to work and care for her grandchildren, surgery for her eyes.
“I have nine medications that I get every month, and mine comes to a little over two hundred dollars,” Simpson said. Prescription medications for her husband, a diabetic, cost $400 a month. “We don’t pay anything, it’s all covered. It’s just amazing.”

Simpson goes to the Family Health Centers of San Diego, which saw an increase of 24,000 patients, almost overnight, after the Medicaid expansion began in January 2014. Dr. Chris Gordon, the center’s assistant medical director, said it was a rush that primary-care clinics have been waiting for ever since President  Obama signed the health law in 2010.

“We’ve anticipated this for years and have been planning for it,” Gordon said. “We have capacity to take on patients. These are patients that haven’t had access before because they just didn’t have the financial means to get in. And now all of a sudden, they actually get to come in, get to spend time with somebody and get to feel like they’re heard.”

Still, problems have plagued the roll out. Three million more people than expected have signed up for Medicaid in California. Other states have also witnessed surges far beyond initial projections, including Kentucky, Michigan, Oregon and Washington State.

As successful as California has been at enrolling millions in Medicaid and in building new primary-care clinics, patient advocates said the Medicaid expansion has exacerbated long-standing shortages in specialty care. Community clinic directors say that it’s often difficult to find cardiologists, orthopedists and other specialists to see their patients and that low-income Californians still face formidable hurdles when they need medical treatment.

For Alessandro Gonzales Gomez, the search for specialty care has been burdensome. Gomez spent years working as a car salesman and auto-parts delivery driver. But now, at age 60 and living alone, he shuffles around his home in an Escondido trailer park, hampered by spells of dizziness that disrupt his daily prayers and curtail his driving.

Gomez is insured under Medicaid, but most of the specialists he needs to see are an hour away. During the drive to a recent doctor’s visit, Gomez said he became dizzy and turned his car around. He went back to the primary-care clinic that had referred him and told them, “’I can’t do this, it’s too far,’” Gomez said. He asked the clinic director about doctors who might be closer, “And she told me that that’s the way it worked out, that there were only certain doctors that would contract with them.”

One of the doctors Gomez has managed to reach is Dr. Ted Mazer, one of the few ear, nose and throat surgeons in San Diego County who accepts Medicaid patients. Mazer said the state does not pay specialists enough to cover their costs.

“If we’re doing some certain surgeries, I can be out of the office for two hours, and we might get $300. My overhead is more than that, so that’s a loss,” Mazer said.

Mazer sees only a limited number of Medicaid patients, but he often agrees to treat those like Qadir Khoshnaw, a 19-year-old in need of a complicated nose surgery. But Mazer said the state is failing to provide this level of care for all Medicaid patients.

“If it was working, I would not have patients coming here from Oceanside and Fall Brook and from the Mexican border and the Imperial County area and the Riverside border,” Mazer said. “I’m one office. Why am I seeing all of those people? Because nobody else is available in their communities to see them. Why not? Because the rates are unacceptable, the hassles from the managed-care plans, as well as the state are unacceptable to most offices to deal with.”

The complaints extend beyond San Diego.

A withering audit by the state of California released this summer found that regulators could not verify if health plans had enough doctors in their Medicaid networks or if the distances patients had to drive were unreasonable. The audit also found that the state’s call centers were overwhelmed, with phone representatives answering just half of incoming calls.

And too often, those obstacles have forced patients to seek help in expensive hospital emergency rooms. In a recent national survey, three out of four emergency room physicians said patient volume had increased, a pressing concern the Medicaid expansion was meant to address.

Emergency room visits at University of California at San Diego Health Systems have increased 11 percent since the Medicaid expansion, says Dr. Christian Tomaszewski, the hospital’s emergency room medical director. “A lot of these patients are coming here looking for sub-specialty care,” he said. “They need an orthopedist for a complicated fracture. They might need a head and neck doctor for some complicated throat problem. And they’re using the emergency department as a gateway to have access to that kind of care.”

At nearby Scripps Mercy Hospital, visits by new Medicaid patients are up 30 percent due to the health law. “It’s a great thing they have insurance,” said Dr. David Cracroft, the hospital’s medical director. “They come for care, but the overall goal was to get them into a primary-care doctor’s office or get them the specialty care that they need, and oftentimes that’s difficult for them to achieve.”

California’s Medicaid program is a budgetary behemoth that falls to Jennifer Kent to manage. As director of the Department of Health Care Services, Kent acknowledged the growing pains as the state stretches to provide health care for nearly one in three Californians.

“We are struggling just as every other state is in terms of how do we bring people into California, how do we grow primary care providers, and then more importantly, how do we provide specialists in areas where there may not be specialists today,” Kent said.

Still, her department is closely measuring complaints and unnecessary hospital stays. Further, undercover agents investigate provider networks and call out deficiencies in the private health plans the state pays to provide care. But Kent says problems with physician access are isolated and are being addressed.

Gov. Jerry Brown, a Democrat, has championed the Medicaid expansion, but like other governors, he has been leery of paying physicians more money just as the state confronts a drop in federal aid. The federal government covers the entire cost of the Medicaid expansion until 2017, but that support scales down gradually, reaching 90 percent in 2020.

Instead, Brown’s administration has pushed the state to spend its money revamping a medical delivery system accustomed to serving poor children, the elderly and disabled to better serve low-income working adults. Across the country, adults on Medicaid are sicker than those with private insurance, and poverty often upends their lives: they change addresses often and can be difficult to reach.

“We have a working population that really has challenges in terms of accessing care in a more traditional sense,” Kent said. “We’re having to work with the providers to say you’re going to have to stretch, in terms of the hours that you offer, using alternative locations and working with nurse practitioners and physician assistants.”
Despite the challenges, there is evidence progress is being made. A recent survey by the Commonwealth Fund found that in states that expanded Medicaid, 93 percent of those who signed up in the past two years are satisfied with their coverage.

For Alessandro Gonzales Gomez, he says he’ll continue to the long drives across the county to see the doctors he needs because his Medicaid card has opened up doors, even if those doors are often difficult to reach.

This story was created in collaboration with PBS Newshour. Jason Kane contributed to this report.

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