In an effort to close the state budget gap, California health officials are proposing a “hard cap” of 10 medical visits per year for needy patients who rely on the Medi-Cal program for health care.
Some patients and health advocates are calling the strategy a "death sentence" for patients who need dialysis treatments to clean their blood or chemotherapy to rid them of cancer. The bipartisan Legislative Analyst’s Office recommended a cap that also grants exemptions for certain services or conditions.
The 10-visit cap [PDF], estimated to save the state $200 million a year, would affect the 10 percent of California patients who rely most heavily on the Medi-Cal program to meet their medical needs.
“It’s barbaric. … What are we to do?” asked one woman who testified during an Assembly budget hearing last week, noting that she relies on routine physician visits for injections of psychiatric medications.
Another woman who testified that she is diabetic and about to start dialysis said: “I’m going to get my death sentence? Because I don’t really know what’s going to happen.”
Though she wasn't at the hearing, dialysis nurse Jeanne Henderson said in an interview that the cut would be devastating to patients. While the Medicare program covers some benefits for patients who experience kidney failure, she said there are wide gaps.
If the 10-visit cap is passed, she said she would expect to see patients coming for emergency care with high levels of waste in their blood, which causes clouded thinking and severe lethargy. Kidney failure patients who get no care can experience deadly buildups of toxins in their blood, she said.
“If they’re going to say only 10 visits a year and dialysis visits count as those treatments, you’ve got less than a month for care,” said Henderson, who managed a dialysis clinic for eight years and now renders emergency care. “That can’t be. That just cannot be.”
Alecia Sanchez, with the American Cancer Society, said the limits would be particularly hard on women who would be quickly cut off five-times-per-week radiation sessions to treat breast cancer.
"I don’t think it’s hyperbolic to suggest that if hard caps are instituted, people will be dying," Sanchez said during the Assembly budget hearing.
Medi-Cal authorities are also proposing a limit of six prescription drugs per month, with exceptions for life-saving drugs.
Bruce Pomer, representing local health officers, questioned whether such a limit would spur the spread of tuberculosis, a condition that can be easily transmitted and can develop antibiotic resistance.
Several people who spoke during the hearing asked whether any savings the state achieves at doctors' offices would be eaten up with soaring hospital bills.
The Department of Health Care Services, which proposed the caps, said it had not undertaken such an analysis.
That agency provided lawmakers with a summary showing that the caps would only impact 10 percent of Medi-Cal patients. That 10 percent of people, though, went to about 40 percent of the 3.3. million annual doctor or medical visits paid for my Medi-Cal, according to an analysis provided to lawmakers.
The notion that a small group of patients can run up a large medical tab is not new in medicine. And some of the latest research indicates that providing those patients with reliable and routine medical care is an effective way to cut medical costs.
In a recent article in The New Yorker magazine, Dr. Atul Gawande detailed how one New Jersey doctor identified patients who were responsible for astronomical medical bills, including one who cost insurers $3.5 million over six years.
By providing the frequently hospitalized patients with regular primary care and social worker and health coach visits, the doctor was able to help those patients change their habits and improve their health. The approach saved money, because it cut down on those patient stays in the intensive care unit.
Such a health care model is often referred to as a “medical home” or “accountable care organization.”
The proposed cap in California would do little to help such an approach flourish here. And it would also deny care to patients who need help in an emergency, such as a diagnosis of cancer or a car crash.
“I don’t think anyone disputes there will be health impacts other than death as a result of these cuts,” said Anthony Wright, executive director of Health Access, a patient advocacy group.
Ultimately the caps would have to be approved by the federal health authorities who recently sent a letter advising states on acceptable ways to cut Medicaid costs.
The suggestions include cutting optional benefits like optometry, podiatry or dental care – a step California has already taken. The letter does not discuss across-the-board caps on care.