California eye docs say they can’t afford Medi-Cal rates. Patients have few other options
Sabrina Navarro called her eye doctor in late January to make an appointment for the youngest of her four daughters. The 11-year-old’s glasses were broken.
The receptionist told Navarro, 38, that the practice was no longer accepting Medi-Cal. Not even for longtime patients.
“I was like, ‘Wait, what?’” Navarro said. “I feel so lost. Twelve years we’ve been going to you, and now I have to figure out where to go and what to do. I don’t even know where to start.”
Navarro’s family is among the estimated 15.7 million Californians enrolled in Medi-Cal, the state program that covers health care for children and adults who live on limited income. Some optometrists say the stagnant Medi-Cal reimbursement rates for eye care services have forced them to choose between providing much-needed care to low-income patients and keeping their businesses afloat.
This leaves patients like Navarro and her family scrambling to find appointments in a marketplace that’s inundated with demand and short on supply.
Medi-Cal currently pays optometrists about $47.50 for an eye exam and refraction, the test the doctor uses to measure the patient’s prescription. While the cost of an eye exam varies, vision insurance provider Vision Service Plan (VSP) estimates the average cost of an eye exam without insurance hovers just under $200.
An analysis from the California Optometric Association, which represents more than 2,500 optometrists in the state, found that California’s reimbursement rates are the third-lowest in the country and haven’t been adjusted significantly in more than 20 years. The nonprofit industry association lobbies lawmakers to support policies that benefit its members.
During his budget announcement earlier this month, Gov. Gavin Newsom called adjustments to reimbursement rates “critical” to the health of Medi-Cal patients. Even as the state faces a $31.5 billion shortfall, the revised 2023-34 budget includes $3.4 billion to increase rates for primary care doctors, maternal care and non-specialty behavioral health care.
The budget does not include increased reimbursement rates for eye care services.
“We are dismayed that the May Revision’s proposed increase in provider rates excludes optometric exams,” said Candi Kimura, president of the optometrists’ association, in response to Newsom’s May budget announcement.
The association wrote a letter in May urging Michelle Baass, director of the Department of Health Care Services, to include increased reimbursement rates for optometrists as part of a budget proposal. The department gave no indication that it would include optometry services this year, but hinted that the department’s proposal next year could leave room for increases.
“A general goal of DHCS’ approach is to invest in Medi-Cal system priorities in ways that provide maximal additional federal matching funds to the Medi-Cal system,” wrote DCHS spokesperson Anthony Cava in an email to The Bee. “For this reason, time is needed to adequately assess program investments so they not only target priorities, but do so in an efficient manner.”
California eye care benefits
California was one of 33 states to expand Medicaid coverage under the Affordable Care Act. Its eye care coverage, which isn’t federally mandated, appears to be one of the most inclusive plans. At the same time, the reimbursement rates lag behind most other states, according to the optometrists’ association.
“California historically has had one of the most generous benefit packages,” said Shana Charles, a professor of health policy at California State University Fullerton and a Medi-Cal expert. “But the issue on the access side is whether or not there’s actually enough providers in the program to be able to get to see anybody.”
A survey that the association conducted earlier this year found that more than one in 10 members reported leaving the Medi-Cal program within the last two years. Forty percent of those doctors said low rates were the reason they left.
Public health experts say access to regular eye exams is just as important as regular dental cleanings or physician check-ups. Vision loss and eye diseases are much more easily treated when detected early, and sometimes vision loss could signal a more pressing condition, such as diabetes, glaucoma and even brain tumors.
For young children, medical experts say that catching a vision disorder early in their life could mean the difference between keeping and losing their vision. Correcting a child’s vision also sets them up for success in school.
William Fleischmann, Navarro’s former optometrist in Rio Linda, said the choice to stop accepting Medi-Cal was one of the toughest decisions he’s made in his nearly 40-year career as an eye care provider. Still, he couldn’t justify the financial hit he’d take from continuing to accept rates that barely covered a third of the cost of his services.
“The math just doesn’t pencil out,” Fleischmann said. “There’s just no way that you can make up the increases for the other expenses with what they’re reimbursing for the exam rates.”
Providers who no longer take Medi-Cal: ‘I can’t do this anymore’
Fleischmann first opened his practice in 1985 and estimated close to half of his patients were on Medi-Cal. He charged patients only $51 for an exam and refraction, and the state would reimburse $42.
Fleischmann’s costs have skyrocketed in the years since. Staff wages have kept pace with inflation, going from just $6 an hour to more than $20 an hour. Rent for his office space soared from $495 to $2,300. His exam rates rose to today’s price of $152.
But the Medi-Cal rate he receives from the state still sits stagnant at $47.50 – a mere 11% increase over nearly four decades.
He didn’t want to turn away his Medi-Cal patients. At first, he convinced himself that taking Medi-Cal was part of his duty as an optometrist. He tried to keep seeing them despite doing so at a growing loss.
“I went into optometry to help other people,” he told himself, “It’s not about the cost.”
But Fleischmann, 62, finally decided a few months ago that he could no longer afford to accept Medi-Cal’s low reimbursement rates – even from patients who he’d seen for decades.
“It was one of the toughest decisions I had to make,” he said, “to finally just say, ‘I can’t do this anymore.’”
Fleishmann said his office still fields calls every day from new and former patients who are in search of a provider that will take their Medi-Cal insurance. All his receptionists can do is suggest they call the number on the back of their insurance card for help finding a new provider.
That’s the advice a receptionist offered Navarro when she called about her daughter’s broken glasses.
Navarro works as a casino waitress and finds time to take charge of her family’s health care in between long shifts. She said she tried calling the number multiple times. The line rang. And rang. Finally, Navarro gave up.
“I just felt so defeated,” Navarro said. “I didn’t know what to do.”
She scrolled through the database of providers who allegedly accepted her Anthem Blue Cross Medi-Cal plan. She called at least three or four different doctors, but they told her they weren’t accepting new patients.
Finally, she called Fleishmann’s office again looking for help. The receptionist gave her the number of another office near Rio Linda that other former patients said was still taking Medi-Cal. Miraculously, Navarro was able to get her family scheduled for appointments.
Although being suddenly dropped from her longtime eye care provider was stressful and demoralizing, Navarro said she completely understood the tough decision Fleischmann made. She harbors no hard feelings toward him or his office.
“When you’re, like, losing money or breaking even, how can you really continue helping?” she said. “I told him, ‘No, you’re fine, I get it – I’m just sad.’”
Long waits, long drives for Medi-Cal patients
Not all Medi-Cal patients are lucky enough to find providers close to home. The survey of optometric association members reported that more than 90% of them said their patients have had a hard time finding a Medi-Cal provider in their area.
Angela DeWalt must drive close to 90 minutes from her home in the hills of Calaveras County to see her doctor at the UC Davis Tschannen Eye Center in Sacramento.
DeWalt has a rare eye condition that causes her cornea, the clear tissue on the front of the eye, to thin and warp and bulge into a cone-like shape. Few doctors specialize in treating the condition, known as keratoconus, and even fewer of them accept DeWalt’s Medi-Cal insurance.
She and her family used to live in Lodi where she saw a doctor who took her insurance. The family moved to Calaveras County, where they could afford property, and she had to switch Medi-Cal plans. That meant she needed a new provider as well. She waited at least six months before she could get in to see her current doctor, Heidi Miller.
DeWalt’s condition requires her to see her doctor annually for a full evaluation and then three to five times a year for contact lens fittings and adjustments. Each visit requires a 125-mile drive round trip.
“We’re seeing patients coming from several hours away,” Miller said, “and oftentimes they say that there was no one locally that they could see for eye care and that they’ve had to wait quite a bit of time to get the referral through to see us.”
Miller said she sees patients who commute from as far away as Modesto and the Bay Area.
DeWalt had to navigate Medi-Cal again to find a pediatric eye doctor for her 5-year-old son Owen, who has autism.
Owen’s preschool teachers told her in early March that he was having trouble focusing at school. The family’s primary care physician sent a referral to the UC Davis Eye Center for Owen.
But after two months with no response, DeWalt finally called and learned that the practice couldn’t accept any new Medi-Cal patients due to a lack of providers. Miller finally stepped in to help arrange an appointment for Owen with one of the pediatricians. He’ll have waited about four months by the time he gets in to see his doctor in mid-June.
“Even when you go through all the proper channels,” DeWalt said of Medi-Cal, “the wait times are extreme.”
Regular eye exams are especially important for children, because detecting vision problems early increases the chances of correcting them. According to the U.S. Centers for Disease Control and Prevention, one in four children in the U.S. has some type of vision problem. But the CDC also estimates that less than 15% of preschool-aged children receive eye exams.
“A lot of permanent vision loss can happen within the first six years,” Miller said. “If we’re not able to access that child within the first six years of their life to prescribe them glasses or contact lenses, or provide the preventative eye care that they need, that vision loss can be permanent, and that will only impact how they learn.”
Optometrists who take Medi-Cal: ‘Where else are they gonna go?’
Stephen Ching and his wife Lori Kam are one of a handful of optometry practices in the Sacramento area who still accept Medi-Cal patients. Financials have been especially hard since the COVID pandemic, which increased their cancellation rate dramatically. But they make the math work for now by booking higher numbers of patients and also cutting their own discretionary spending at home.
“We’re really not profitable seeing Medi-Cal. We just do it because I don’t want to abandon all these patients,” Ching said. “If we stopped taking it, I don’t know where they’re gonna go.”
The Bee spoke with 24 optometry practices in the Sacramento area who, according to a list curated by Vision Service Plan, are still accepting Medi-Cal patients.
Seven providers said the list was outdated and they no longer took Medi-Cal of any type.
Seven clinics said they had wait times of at least a month due to an influx of Medi-Cal patients and their limited number of appointments.
Ten practices said they were accepting new Medi-Cal patients and could book them within three or fewer weeks. But most of the clinics said they only accept certain managed care plans, such as Anthem Blue Cross, which further limits the pool of providers.
Lisa Rivera, who’s been a Medi-Cal patient of Ching’s for almost 30 years, refuses to entertain the idea of seeing any other doctor. Rivera has Type 2 diabetes, which sometimes makes her vision go blurry, and she no longer drives places on her own. Ching’s office is close to her home. If for some reason he could no longer accept her insurance, she says she’d pay out of pocket.
“He treats us like family,” Rivera said. “When you go to his office, he makes you feel welcome.”
Doctors Heidi Pham-Murphy and her husband Thomas Murphy, who operate four optometry clinics in the Sacramento area, both grew up on Medi-Cal. Pham-Murphy said their decision to accept Medi-Cal patients is their way of giving back to the community. But she can’t deny the financial difficulty of accepting such low rates.
“Almost my entire career, the rates haven’t changed,” she said. “It makes it very difficult to sustain people, and sustain a business, while taking Medi-Cal.”
Ching said a boost to the rates would help ensure that he can continue to see Medi-Cal patients. The optometrists’ association has written letters to the director of the Department of Health Care Services, Michelle Baass, asking her to submit a budget request that would increase the rates.
If the rates stay stagnant, Ching will have to make a tough choice.
“We’re just kind of making ends meet,” Ching said. “I hope it doesn’t reach the point where it’s like, ‘We just can’t do it anymore.’”
