Doctor shortage slows reform

The blurry vision began early last year. Roy Lawrence ignored it as long as he could. But after falling off a ladder at his construction job, he knew he had to see a doctor.

He went to a community health clinic in South Los Angeles, where doctors determined he had diabetes and cataracts. The clinic could manage his illness but referred him early this year to the county health system for eye surgery.

Nearly a year later, Lawrence, a Jamaican immigrant without insurance, still is waiting for the operation. His vision has deteriorated so much that he is considered legally blind.

“I want to see again,” he said. “I’ve been waiting a long time.”

Lawrence, 49, and patients like him are posing a critical challenge for the planned overhaul of the nation’s healthcare system. Federal officials are investing billions in community health centers like the To Help Everyone (T.H.E.) Clinic, where Lawrence’s problem was diagnosed, with the hope that they can keep more patients out of high-cost emergency rooms.

But a dearth of specialists available to low-income patients presents one of the bigger hurdles facing the country as it tries to bring spiraling healthcare costs under control. Doctors say meeting new government mandates to keep patients healthy and out of hospitals -- a linchpin in reducing medical spending -- will be virtually impossible without the ability to make timely patient appointments with specialists.

By the end of the decade, the nation will be short more than 46,000 surgeons and specialists, a nearly tenfold increase from 2010, according to the Assn. of American Medical Colleges. Healthcare reform is expected to worsen the problem as more patients -- many with complex and deferred health needs -- become insured and seek specialized treatment.

Many of the newly insured will receive Medi-Cal, the government plan for the needy as administered through the state of California. Clinics already struggle to get private specialists to see Medicaid patients because of the low payments to doctors. Last week, an appellate court decision authorized the state to move forward with 10% cuts in Medi-Cal reimbursement, which could make finding doctors for those patients even more difficult.

“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” said Mark Dressner, a Long Beach clinic doctor and president-elect of the California Academy of Family Physicians. “We’re really disappointed and concerned what it’s going to do for patient access.”

The healthcare overhaul includes initiatives aimed at reducing shortages of general medicine professionals but does little to increase the availability of specialists.

In Los Angeles County, the sheer volume of poor or uninsured patients needing specialist services has long overwhelmed the public health system, creating costly inefficiencies and appointment delays that can stretch as long as a year and half.

Patients’ conditions often must be dire for them to see a neurologist, cardiologist or other specialist quickly. Community clinics try to bypass the backed-up formal government referral system by pleading, cajoling and negotiating to get less critically ill patients like Lawrence moved up on waiting lists.

“Where needs are absolutely critical, we are able to work out special arrangements,” said Rise Phillips, chief executive of T.H.E. Clinic. “That is not the norm. That is, rather, the exception.”

At times, clinic staff members are forced to work against one of their key missions by sending patients to emergency rooms to increase the odds of their seeing a specialist more quickly.

The challenge can be seen in Belinda De Leon’s cubicle in a small, windowless back corner of T.H.E. Clinic. A referral specialist, De Leon spends her days trying to speed up appointments for the center’s clients -- and fielding calls from patients wanting to know how much longer they have to wait. At any given time, she’s juggling more than 1,000 pending referrals.

One involves uninsured housekeeper Juana Barrera. Barrera, 45, has been waiting since April 2011 to see a gastroenterologist and get a colonoscopy. She has had bleeding off and on and recently started having pain in her stomach.

On a recent visit, she told De Leon she is scared to wait any longer. But she can’t afford to pay for the test out of pocket. “I’m hoping it’s not anything like cancer,” she said.

De Leon promised to update Barrera’s referral paperwork to indicate she is experiencing pain. “Hopefully that will help,” she said.

Waits for specialist appointments vary dramatically, depending on the type of specialist needed. Patients willing and able to travel across L.A. County to specialty clinics may be able to see a doctor within a month or two. Others who lack transportation and must go to a nearby facility can wait up to a year for a dermatologist or neurologist and up to 18 months for a cardiologist or ophthalmologist.

The county is trying to make the system more efficient, reduce wait times and ensure that those who don’t need more advanced care don’t overburden the system, said Mitch Katz, head of the L.A. County Department of Health Services. County officials risk losing newly insured patients, along with government funding, if they can’t find ways to reduce the bottleneck.

One focus is using technology to improve communication and better screen patients. A pilot program, for example, is allowing primary care doctors at community and public clinics to quickly transmit patients’ medical information via computer to a public health specialist for a consultation.

The electronic consults are streamlining referrals and helping clinic doctors make better treatment choices, said Louise McCarthy, executive director of the Community Clinic Assn. of Los Angeles County.

During an August visit to T.H.E. Clinic, Lawrence saw nurse practitioner Sandeep Lehil for the first time. He told her he was controlling his diabetes with medication and a modified diet. But his vision wasn’t getting any better.

“My eyes are really bad,” he told Lehil. “I can barely see.”

Lawrence’s medical record showed that he wouldn’t be seeing an ophthalmologist for many months.

“That’s a long time to live with blurry vision,” Lehil said.

“By that time, I’ll be blind maybe,” Lawrence responded.

Lawrence, who has a soft voice, an accent and a lanky frame, arrived in the U.S. nearly 20 years ago to pick apples, and overstayed his visa. He can’t work or drive, and he relies on others to cook meals to avoid burning himself. His immigration status prevents him from getting health insurance or unemployment benefits. He lives with a friend, spending most days listening to a television he can barely see. When the phone rings, he lifts it almost to his nose to see who is calling.

In mid-October, Lawrence was back at the clinic and saw a different, fill-in doctor who knew nothing about his situation, nor when his surgery would be scheduled. “You haven’t received any notice?” asked physician David Hwang. “No, not yet,” Lawrence answered, adding that he checks his mailbox every day.

De Leon, the referral clerk, later gave Lawrence unwelcome news: The wait to see an ophthalmologist at the county’s Harbor-UCLA Medical Center was still about a year. She said she was trying to get him an appointment elsewhere sooner.

Weeks later, Lawrence took matters into his own hands. With the help of a friend, he took three buses to reach the emergency room at Los Angeles County/USC Medical Center northeast of downtown. He waited several hours but finally saw an emergency room physician, who managed to get him an appointment the next day with an eye doctor.

“You have to do what you have to do,” Lawrence said.

At the medical center’s specialty clinic, ophthalmologist Simon Bababeygy told Lawrence his cataracts probably were caused by his diabetes, high blood pressure and high cholesterol.

He described the surgery he would perform, on one eye at a time. And he spoke the words Lawrence had been waiting for: He should be seeing much more clearly by the end of the year.

Preparing for the surgery, doctors got an abnormal result on a heart test. Now, Lawrence has to wait to see a county cardiologist before going back to Bababeygy to schedule the eye operation. He has no idea how long that could take.

“Every time, it’s something else,” he said. “My eyes are getting worse. And now it’s my heart.”

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Times staff writer Anna Gorman reported aspects of this story while participating in the California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School of Journalism.

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About this series

This is one in a series of occasional stories about the To Help Everyone Clinic in South Los Angeles. The clinic is one of about 1,250 federally funded health centers that treat more than 20 million patients in poor urban and rural areas around the nation. They are considered a critical part of the Obama administration’s healthcare overhaul and efforts to lower costs, improve quality and expand access. As part of their reporting, Times staff writer Anna Gorman and photojournalist Gina Ferazzi spent three months at the health clinic, interviewing patients, providers, administrators and staff members.