California regulators announced last month plans to evaluate whether safety-net patients face improperly long waits to see medical specialists in Los Angeles County, the nation’s second-largest public health system. That investigation — which aims to determine whether these wait times violate managed-care standards — raises fundamental questions about the quality of care for safety-net patients nationwide, in the midst of a pandemic that disproportionately affects the most vulnerable people.
One in 5 Americans — and 1 in 3 Californians — have their health care covered by Medicaid, the public health insurance program for low-income individuals and families. These people, along with the approximately 10% of Americans who lack health coverage entirely, constitute the safety-net population.
The California review was launched in the wake of a Los Angeles Times investigation which found that safety-net patients served by the L.A. County Department of Health Services — which operates four public hospitals and a network of ambulatory care facilities for safety-net patients — wait an average of 89 days for specialty appointments. For some specialties — like dermatology and nephrology — the delays were even longer. Guidelines from the California Department of Managed Healthcare say that patients should be able to access a specialist within 15 days for non-urgent appointments. In most regions of the U.S., patients with commercial insurance wait under 30 days for specialty appointments.
Typical wait times in other safety-net settings are not well-established. Such information is essential to put the Los Angeles County findings in context and to identify lapses in patient care elsewhere in the country.
Nevertheless, we believe that it shouldn’t take a newspaper investigation to uncover a problem like this. A three-month wait for specialty care would be hard to hide if a public Medicaid scorecard — similar to those that have long been used to gauge the care of patients covered by Medicare and commercial providers — were available.
In California, for example, the state website offers a quality scorecard for commercial medical providers, ranking them on metrics such as breast cancer screening, diabetes care, and patient experience (the latter would be an indicator of unacceptably long appointment wait times). The Centers for Medicare and Medicaid Services produces a similar scorecard for Medicare providers across the country. These scorecards provide basic accountability for health care groups, helping identify those performing significantly below the standard.
Several years ago, our teams at the USC Gehr Family Center for Health Systems Science and Innovation and the USC Center for Health Journalism set out to change that. We planned to help create a public scorecard for Medicaid groups, starting locally in Los Angeles. We anticipated that the project would not be easy, but we never could have imagined the resistance we encountered.
As we documented in a series of columns, safety-net leaders who publicly professed their commitment to quality opposed our efforts. Some were concerned that revealing low-quality rankings might put pressure on already overburdened systems. Others worried that the standard scorecard metrics would not easily apply to safety-net populations.
Many, however, didn’t want to do it because they didn’t have to. The leader of one large Medicaid group told us by email, “Basically we do not know what we have to gain by sharing the info! What’s in it for us?” Without a mandate to share data, this perspective prevailed.
In our experience, the majority of clinicians who care for safety-net patients do so out of a genuine desire to help vulnerable individuals and families, even though it can be hard to care for Medicaid patients. They sometimes miss appointments because they depend on unreliable public transit in sprawling Los Angeles. Many do not regularly go to the doctor, as they cannot leave work for appointments without getting their pay docked. And they are more likely to live in neighborhoods where they cannot exercise safely or buy healthy food, increasing their likelihood of having chronic conditions that are hard to manage, such as diabetes or high blood pressure.
Health care providers in these settings — including the many dedicated clinicians working in the Los Angeles County health system — must contend with hurdles that clinicians who care mainly for patients covered by commercial insurance face far less often.
But this does not excuse safety-net health leaders from their responsibility to the public and to their patients. Mandating scorecards for Medicaid provider groups — ideally with data on individual clinics and specifically tailored to reflect the needs of low-income populations — would provide information that could empower patients and families to make more informed health care choices. Medicaid provider scorecards would also enable policymakers to reward high-performing groups by investing in their expansion and channeling patients their way while demanding better work from poor performers or even ending their contracts.
With the annual Medicaid budget now topping $600 billion nationwide and Covid-19 threatening the health of our country’s vulnerable residents, we believe that basic public accountability is in order for people covered by Medicaid. We urge state and federal lawmakers to legislate a required Medicaid provider report card, similar to what has been available for decades for people covered by Medicare and commercial insurance.
Michael Hochman is a primary care doctor, director of the USC Gehr Family Center for Health Systems Science and Innovation and host of the “Healthy Skeptic, MD” podcast. Michelle Levander directs the USC Center for Health Journalism and is editor in chief of its content site, CenterforHealthJournalism.org.