The phones begin ringing at 7:30 a.m. at the Child & Adolescent Clinic’s Vancouver office. The doors don’t open to patients for another hour, but Evelyn Paxton is at the front desk, headset on, taking calls to fill same-day sick appointments.
The clinic has a few same-day appointments each day, and on Mondays and Tuesdays, the clinic stays open two hours late, until 7 p.m., to accommodate more sick kids.
But Tuesday, all appointment slots were filled by about 8:30 a.m.
Those who can’t be seen the same day are given a few options: an appointment at the clinic’s Longview office, a trip to urgent care or calling again the next morning.
“They may not like the options I give them, but they can make a choice based on the options I have,” Paxton explained.
As one of only a few local health clinics with its doors open to new pediatric Medicaid members, Paxton fields calls all day from parents seeking medical appointments — both same-day appointments and routine well-child checkups.
The same is true at Sea Mar Community Health Centers, which also has an open-door policy for Medicaid members.
“It has been challenging because of the size of the population we need to serve,” said Harshiem Ross, Sea Mar’s southern regional vice president for medical operations. “Most of my pediatric providers are pretty slammed every day.”
Not taking new patients
In Clark County, 62,404 children are enrolled in Medicaid managed-care plans. Molina Healthcare of Washington manages the care of 52,273 of those children.
While Molina has successfully expanded its network of primary care providers serving adult and pediatric Medicaid members — going from just 50 primary care providers in January 2015 to 345 providers this month — it has seen a dramatic decline in the percentage of primary care providers willing to accept new Medicaid members.
In January 2015, 52 percent of Molina’s primary care providers were accepting new Medicaid members. This month, just 13 percent of providers have their doors open to new Medicaid members, said Peter Adler, president of Molina Healthcare of Washington.
“An ever-increasing percentage of primary care physicians have closed their doors to accepting new Medicaid beneficiaries,” Adler said.
From the state’s perspective, however, Clark County has enough pediatric primary care providers to serve the Medicaid population.
“From an adequacy standpoint, there is adequate access,” said Preston Cody, an assistant director with the Health Care Authority, which oversees the state’s Medicaid program. “We’re not hearing about a significant issue, and we’re not seeing an issue in the data.”
In Clark County, 271 primary care providers are seeing pediatric Medicaid members, according to the Health Care Authority. The majority of those providers (162 providers) are family medicine physicians and nurse practitioners. About 60 are pediatricians.
A quick ratio of providers to pediatric patients — 271 providers to 62,000 patients — shows a “pretty good ratio,” Cody said.
What those numbers don’t reveal, however, is how many Medicaid patients each provider is seeing, and that is problematic, said Sarah Rafton, executive director of the Washington Chapter of the American Academy of Pediatrics.
“We don’t know how many patients are being seen by those providers who say they accept Medicaid,” she said.
Without that information, it’s tough to get a clear picture of whether access is adequate, Rafton said.
The managed care plans have to report to the Health Care Authority if contracted providers are limiting the number of Medicaid clients they’re accepting, but they don’t have to report how many of a provider’s patients are Medicaid members. So the Health Care Authority doesn’t know if a pediatrician’s case load includes 10 Medicaid members or 1,000 — only if the provider is accepting or limiting Medicaid members.
For a decade, Deborah Baker took her three children to The Vancouver Clinic for primary care. But nearly two years ago, when Baker tried making routine appointments for her kids — now 13, 15 and 17 — she was told they were no longer Vancouver Clinic patients.
“They said, ‘We are no longer taking new Medicaid patients,’ and I said, ‘We’re not new,’ ” Baker said. “I was in tears.”
In May 2014, The Vancouver Clinic announced it would no longer accept new Medicaid clients. Declining reimbursement rates and the increasing number of Medicaid clients threatened the clinic’s financial stability, clinic officials said at the time.
Clinic officials said the clinic would continue to see existing patients but would not accept new members and would not replace existing Medicaid clients as they left the clinic or were removed from the Medicaid program. Currently, The Vancouver Clinic has more than 10,000 pediatric Medicaid patients — about 35 percent of its pediatric patients.
When Baker’s children’s pediatrician left the practice, Baker learned that meant her children were no longer considered by the clinic to be established patients.
“I was just blindsided, totally blindsided,” Baker said.
“It was very frustrating because then it was on us to find a new doctor for our kids,” she added.
Luckily, Baker’s first call was to the Child & Adolescent Clinic. While the clinic was open to new patients, the wait time for appointments is longer, Baker said. She typically schedules routine appointments three months in advance.
But when unexpected things come up, Baker learned this summer it can be tough to get her kids in to be seen.
Baker’s son chipped a bone in his knee while at an out-of-town summer camp. The urgent care provider wanted him to be seen by his primary care provider within a week. Baker called the Child & Adolescent Clinic. The soonest they could get him in to see his doctor was six to eight weeks. Fortunately, the clinic was able to squeeze him in at its Longview location.
“They’re that booked,” Baker said.
And that’s not unusual.
The Child & Adolescent Clinic currently has two full-time and one part-time pediatricians at its Salmon Creek office. In the last year, those providers have seen 3,088 Medicaid clients, which account for 85 percent of their practice.
The wait time for a routine appointment for an established clinic patient is about five weeks. Only one of the clinic’s providers in Vancouver is seeing new patients, and his next available appointment is about eight weeks out, said Kimberley Robbins, clinic administrator.
Sea Mar has similar troubles.
Sea Mar has more than 12,000 pediatric patients assigned to its providers in Clark County. The clinic has just three pediatric providers — two at its Delaware Lane office and one at the Salmon Creek location — but also has family practice providers seeing children at offices without a pediatric provider, such as the Battle Ground office.
On average, Sea Mar can get new patients in to see a provider within two weeks. The problem, however, is the number of new patients needing care makes it tough for pediatric providers to see established patients when they’re sick, Ross said. As a result, sick patients are often sent to a family practice provider, just so they can be seen in a timely manner, he said.
The clinics do hold four to six same-day visits for each provider. But that’s only 18 appointments, and they fill up quickly.
“We’re really inundated,” Ross said.
Health plan officials and pediatric providers point to two reasons for primary care access issues: low reimbursement rates and a shortage of providers.
“Financially, they’re not able to keep their practice afloat if their percentage of Medicaid patients gets too high,” said Adler, with Molina. “That’s the reason we’ve been consistently told.”
As the state prepared to expand its Medicaid program, the Affordable Care Act provided a payment increase for certain primary care providers in 2013 and 2014. During those two years, the Medicaid reimbursement rates for pediatric physicians, among others, was increased to Medicare reimbursement rates, which are still lower than those of commercial insurance plans.
It was up to the states to continue to pay those increased rates after the first two years. Washington did not.
Under the enhanced rates, a physician was reimbursed $73.39 or $108.29 for an office visit for a child, depending on the type of services provided. Under the regular rates, providers are reimbursed $58.37 or $86.11 for those same visits.
This legislative session, the Washington Chapter of the American Academy of Pediatrics is advocating for reinstatement of the Medicare-Medicaid equity bump, said Rafton, executive director of the organization. Doing so would require $7.5 million per year, she said.
“Our position is that $7.5 million is an incredibly sound investment in the most effective care — and that’s preventive care in the primary care office,” Rafton said.
Molina is continuing to work with the Academy to champion the increase, as well, Adler said.
“That will help address the very issue as to why, at this point, 87 percent of all the primary care physicians in Clark County no longer accept new Medicaid patients,” he said.
Molina and local medical providers are also working to increase the number of pediatric providers in the community.
In addition to managing care for Medicaid members, Molina runs health clinics in several states, including one in Everett. Molina officials are evaluating whether a Molina clinic could serve as a “safety valve” in Clark County.
“We are evaluating whether Southwestern Washington might, because of the access challenges, because so many practices have closed to new Medicaid beneficiaries, if it would be a beneficial county for us to open a Molina medical clinic,” Adler said.
That review should be done by July.
The Child & Adolescent Clinic and Sea Mar are adding staff to keep up with demand.
A new full-time pediatrician is starting at the Child & Adolescent Clinic this month, and the clinic’s current part-time provider will become full time next month. The clinic also plans to add a fifth full-time pediatrician this spring.
Sea Mar is currently recruiting a pediatric provider for its new east Vancouver clinic and has openings at other local clinics. The goal is to get at least one pediatric provider at each of the clinic’s five Clark County locations, Ross said.
“This is very important that we reach these children and give them the appropriate care,” Ross said. “It impacts so many aspects of their lives.”
“We’re committed to Medicaid and that managed-care community,” he added.