Combating to see a specialist amplified ache for Southern California girl – Orange County Register

By Molly Citadel Work, KFF Well being Information

Teresa Johnson can’t escape the ache.

It’s as if she’s getting pierced by needles throughout her physique, unexpectedly. At night time, she generally jolts out of sleep considering bedbugs are attacking her. Nevertheless it’s simply the unfailing ache — day in and time out.

Johnson, 58, mentioned her ordeal began in September 2022, when she went for a CT scan of her stomach after a bout of COVID-19. Although Johnson warned the lab she was allergic to iodine, she believes the lab tech used it in an injection, triggering an allergic response. She spent the following three weeks within the hospital, feeling as if her physique was on hearth.

When she was discharged to her house on the base of the San Jacinto Mountains in Riverside County, Johnson mentioned, her high quality of life deteriorated and her frustration mounted as she waited for her Medi-Cal plan to get her assessed by a specialist. She might barely stroll or stand, she might now not cook dinner for herself, and generally she couldn’t even elevate her leg excessive sufficient to step into the bathtub.

“I might by no means want this on anyone,” Johnson mentioned whereas rocking backwards and forwards on the sofa to nonetheless the ache. “You don’t know for those who ought to cry, or simply say OK, I could make it via this. It messes with you mentally.”

Johnson mentioned her major care physician informed her he wasn’t positive what triggered the ache however suspects it was compounded by the lingering results of COVID-19. Johnson, who’s diabetic, developed neuropathy, a sort of nerve injury, probably after the allergic response prompted her blood sugar ranges to skyrocket, her physician informed her.

He referred Johnson, who receives care via California’s Medicaid program for low-income individuals, to an endocrinologist in March. However, Johnson mentioned, she was not provided well timed appointments, and it took greater than six months, 4 referrals, a number of complaints to her well being plan, and a authorized assist group’s assist to lastly snag a telephone name with an endocrinologist in mid-September.

Entry to specialists — from gastroenterologists to cardiologists — has been a long-standing problem for a lot of Medi-Cal sufferers, particularly these in rural areas or areas going through employees shortages. The Inland Empire, the place Johnson lives, has the second-lowest provide of specialists within the state, in accordance with the California Well being Care Basis. (KFF Well being Information is the writer of California Healthline, an editorially impartial service of the California Well being Care Basis.)

The state Division of Managed Well being Care, which regulates most Medi-Cal well being plans, requires plans to get sufferers in to see specialists inside 15 enterprise days, until an extended ready time wouldn’t hurt the affected person’s well being. However the timeline usually seems to be very completely different in actuality.

“It’s arduous to get a specialist to contract for Medi-Cal sufferers. Interval,” mentioned Amanda Simmons, government vp of Built-in Well being Companions of Southern California, a nonprofit that represents group well being clinics. “Specialists don’t wish to do it as a result of reimbursement charges are so low.”

Johnson mentioned she made her first name in March to the endocrinologist assigned by her Medi-Cal insurer, Inland Empire Well being Plan, and that the workplace provided her an appointment a number of months out. Over the following 4 months, she obtained three extra referrals, however she mentioned she obtained the same response every time she known as. When Johnson objected to the prolonged wait occasions, requesting earlier appointments, she was informed there was no availability and that her situation wasn’t pressing.

“They informed me it wasn’t essential,” Johnson mentioned. “And I requested, ‘How would you recognize? You’ve by no means seen me.’”

Esther Iverson, director of supplier communications for the plan, declined to discuss Johnson’s case however mentioned the plan makes each effort to fulfill the 15-day requirement. It may be difficult to fulfill the usual, she mentioned, due to an absence of accessible physicians — particularly for sure specialties, similar to endocrinology and ache administration.

She pointed to the nationwide doctor scarcity, which is extra pronounced in rural areas, together with elements of San Bernardino and Riverside counties, the place the plan operates. She additionally famous that many physicians determined to depart the sector or retire early due to burnout from the COVID-19 pandemic.

On the similar time, she mentioned, the plan’s enrollment ballooned to 1.6 million as eligibility expanded in recent times. Statewide, greater than 15 million Californians are enrolled in Medi-Cal.

“The best precedence for us is well timed entry to high quality care,” Iverson mentioned.

Throughout her quest, Johnson enlisted the assistance of Inland Counties Authorized Providers, which supplies free authorized illustration to low-income residents. They known as the plan a number of occasions to request earlier appointments however obtained mired in bureaucratic delays and ready intervals.

In a single occasion in August, after the insurer informed Johnson it couldn’t meet the 15-day timeframe, her authorized consultant, Mariane Gantino, filed an enchantment, arguing that Johnson’s request was pressing. The insurer’s medical director responded inside just a few hours denying the declare, saying the plan concluded that her case was not pressing and {that a} delay wouldn’t trigger a critical menace to her well being.

“I’m so burned out after coping with this for thus lengthy,” Johnson mentioned in mid-September. “Why have they got the 15-day legislation if there aren’t going to be any penalties?”

A number of days later, Johnson lastly obtained the decision she had been ready for: a suggestion of a telephone appointment with an endocrinologist on Sept. 18. Throughout the appointment, the physician adjusted her diabetes and different medicines however didn’t instantly deal with her ache, she mentioned.

“I’m in the identical place,” Johnson mentioned. “I’m nonetheless in ache. What’s subsequent?”

Through the years, Johnson has labored varied jobs — from driving 18-wheelers cross-country to weaving hair — however her most constant work was as a caregiver, together with to her six youngsters, 21 grandchildren and three great-grandkids, with one other great-grandchild on the best way. Now, due to her excessive ache, the roles have been reversed. A daughter and granddaughter who reside together with her have change into her full-time caregivers.

“I can’t do nothing. I can’t handle my grandkids like I used to,” mentioned Johnson, who sleeps a lot of the day and wakes up solely when her ache treatment wears off. “I used to be planning to handle the brand new child that’s coming. I in all probability can’t even maintain her now.”

This text is a part of “Faces of Medi-Cal,” a California Healthline sequence exploring the affect of the state’s safety-net well being program on enrollees.

This text was produced by KFF Well being Information, which publishes California Healthline, an editorially impartial service of the California Well being Care Basis. 

KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working applications at KFF—an impartial supply of well being coverage analysis, polling, and journalism. Study extra about KFF.