When Shani Muhammad, MD, meets with her patients, they often talk about more than health.
As an urgent care physician in San Jose, most of Dr. Muhammad’s patients are Medi-Cal recipients or uninsured. And one common refrain is the difficulty they have accessing healthcare, making appointments — and even interacting with other providers.
“They don’t feel like the physicians are working as hard to figure out what’s going on with them, or listen to or understand them,” she said. “I had patients complain, generally, of feeling discriminated against, or treated like their intelligence level wasn’t as high, or of not having things explained to them because of the assumption that they won’t care.”
“A lot of times they express the statement, ‘They didn’t get me,’ ‘They didn’t try to get me,’ ‘They were judging me,’ or ‘They were making assumptions about me,’” she said.
Dr. Muhammad’s patients are not alone.
Data released in June by California’s Department of Health Care Services show that nearly 7,000 Medi-Cal patients filed official grievances about “poor provider/staff attitude” in the last three months of 2017, the most recent data available, making it the top quality-of-care complaint. Anthony Cava, a spokesperson for the healthcare agency, said that because this grievance category is new, the department can’t yet assess which direction this dissatisfaction is trending.
But advocates say that issues of stigma, cultural competence and language barriers have long been problems for Medi-Cal patients in their interactions with providers.
“We know that there’s an alarming number of consumers who have had poor experiences with care,” said Kimberly Chen, government affairs manager for the California Pan-Ethnic Health Network. “And what you get when you have providers who don’t approach patients with cultural humility is you prescribe incorrect treatment, undertreatment or overtreatment, and then ultimately people’s health suffers.”
When the California Black Health Network recently embarked on a seven-city listening tour to better understand the needs of black patients across the state, one common complaint was the stigma of Medi-Cal, said the group’s deputy director Angelo Williams.
“‘The issue is, I’ll use the card, but I’m treated in a different way because I’m using the card,’” he recalled people saying. “The stigma is that in using the card, it reinforces some of the external stereotypes, the imposition of an inferior status.”
One consequence of this, Williams said, is that many African-Americans who are eligible for Medi-Cal aren’t using it for fear of how they’ll be treated in the doctor’s office.
And for those Medi-Cal patients who do seek out care, there can be stigma in not already being in good health, said Chen. She’s seen this particularly at the dentist.
“Older folks with dental needs are going to certain providers who may have unfair attitudes towards them,” she said. “Because they haven’t had the opportunity to have dental care, their teeth might be in poor condition and they feel shamed by it. They say, ‘I know, I didn’t have the care, I’m trying to do the right thing, I’m trying to get some cosmetic things fixed so I can get a better job,’ but they have these judgmental feelings.”
Language can also be a problem.
Rocio Gonzalez, health policy advocate for the Mixteco Indigena Community Organizing Project (MICOP), which serves the indigenous immigrant community in Ventura County, said that many of the monolingual Medi-Cal families she works with have trouble making and getting to appointments, and navigating the healthcare system in general.
When they do engage with providers, language and cultural barriers can put families at even greater risk than just poor care. One new mother, said Gonzalez, scheduled a doctor’s visit for her baby, but on the day of the appointment, was unable to get there because the transportation service MICOP had arranged didn’t show up.
“Child Services ended up getting involved because they thought Mom was being negligent,” said Gonzalez. “But that wasn’t the case at all.”
In the past year, MICOP has partnered with Gold Coast Health Plan to implement a new pilot program to fund a health case manager — who speaks Mixtec and Spanish — to help Medi-Cal families navigate the healthcare system, make appointments and get transportation and translation services. Since August 2017, the new health case manager has helped 251 patients in 86 families, Gonzalez said.
The problems between Medi-Cal patients and their physicians are also structural, advocates said, and require structural changes.
For Williams, the stigma also has to do with the low reimbursement rate physicians are paid for serving Medi-Cal patients and the lack of financial incentives for serving this population.
“Some practitioners said there’s the constant back-of-the-mind feeling that they’re not going to be paid on time, so if they accept Medi-Cal patients, they’re subsidizing their service, because they could go to private insurance and get paid quickly,” he said.
“We have to figure out how to incentivize care for African-Americans, Latinos and low-income Californians in general, because the system does not offer incentives to provide for the least of these,” Williams said. “It’s developed to provide efficiencies.”
Cava of the Department of Health Care Services, meanwhile, said that the department “performs a medical audit annually, which includes a full review of the health plan grievance and appeal system/process, and contacts health plans on a quarterly basis if they are deemed to have a high grievance and appeal submission rate.” Prior to collecting specific data on Medi-Cal patients’ experiences with providers, these grievances were lumped together under “quality of care” complaints.
For Dr. Muhammad, improving Medi-Cal patient experience starts with clinics. She has seen — and worked in — clinics with run-down furniture, extension cords hanging from the ceiling, unfriendly staff and even dead roaches on the floor. This, she said, only reinforces the perception that Medi-Cal customers are treated differently.
Instead, she said, there should be greater oversight for the federally qualified health centers that primarily serve Medi-Cal patients, ensuring that facilities are clean, aesthetically pleasing and offer a range of programs to promote community wellness.
“We need to go around and say, ‘If you get federal money to provide services to these patients, it has to be put back into the clinic and not just into the pocket of the CEO and the board of directors; it has to be invested back into the community,” she said.
“That would be a big step in making people feel that we’re here to serve you.”