More than a year after the passage of the Affordable Care Act, nearly three million Californians are newly insured by Medi-Cal, California’s health insurance program for the very poor, but many of them are still struggling to get the care they need.
In California, most Medi-Cal recipients are in managed care, and a recent federal government report found lax oversight of the plans. In Los Angeles County as in many parts of the state, consumers regularly give their Medi-Cal managed care plans failing grades in annual surveys. The problems have caught the ear of state legislators and the newly appointed director of the Department of Health Care Services, who has promised to monitor Medi-Cal managed care to make sure poor people can get health care.
Still, improvements can’t come soon enough for patients like Mirna Amaya, a Los Angeles woman who faced a dangerous and painful wait for medical care that her health plan has finally allowed her to have.
Amaya, 58, waited more than four months to see an endocrinologist, ever since she was discharged from the hospital last September after suffering complications of pancreatitis.
She was in a lot of pain, and needed ongoing treatment by a specialist to stave off infection, breathing problems, diabetes, and kidney failure, all of which could result if her disease goes unchecked.
“On a scale of one to ten, I always say my pain is a 15,” Amaya said. It’s a pain that doesn’t let you breathe, she added.
But for months, Health Net, Amaya’s Medi-Cal managed care plan, said the only endocrinologist it would approve was in San Bernardino County—more than 60 miles from her northeast Los Angeles home, and she couldn’t travel that far, especially on an ongoing basis.
What’s more, Amaya said that if the procedure she needs –an endoscopy with ultrasound—went wrong, hospitalization away from her assigned institution wouldn’t be covered. Still Health Net steadfastly refused to pay to her to see a specialist closer to her home.
In December, she sought help at Neighborhood Legal Services, a legal aid group, where attorney Cori Racela pressed Amaya’s case with Health Net. Amaya reported that she got word in late February that she was finally approved to see a specialist closer to her home.
It could be Racela’s advocacy that won the day, or said Amaya, her own threat to go to the press with her issues.
Medi-Cal patients have long had to fight to get the care they’ve needed, Racela said.
Before the ACA, denials of care were probably the number one problem that came to her, Racela said. Now, the issue has been overshadowed by the sudden removal of some 400,000 people from the Medi-Cal rolls, a bureaucratic nightmare that has caused its own set of access issues.
“They have chemotherapy or surgery or just regular medicine that they need every day,” she said.
While many patients like Amaya have managed to retain their Medi-Cal eligibility, they still can’t get their insurer to provide the care they need, Racela said.
In some ways, they face the same frustrations as many other Americans with managed care. But Racela said the problems are harder to handle if you’re new to insurance altogether, or if English isn’t your first language, as in Amaya’s case.
Racela thinks the obstacle in Amaya’s way was the Independent Physician Association that contracts with Health Net to provide her care.
IPAs are groups of doctors who join forces to negotiate with insurers. In exchange for a fixed rate per head, the IPA agrees to take care of all of the physician needs of a group of patients.
Racela said she suspects that Amaya’s IPA doesn’t include an endocrinologist that is near her home, and that Health Net was unwilling to pay extra to send her to one. It’s a fairly common issue, Racela says, and not specific to Health Net.
Health Net officials declined an interview request, but spokesman Brad Kieffer wrote in an email, “If members believe they are not receiving timely access to their [primary care physician] or any other service, we encourage them to contact us so we may step in and help.”
Racela notes that the health plans are indeed equipped to help patients who can argue their own cases. But those who are ill and inexperienced with insurance rarely make good advocates for themselves. What’s more, Racela said health plans often dissuade their members from filing grievances, which are tallied by the state and which are the first step in a process that can lead to a formal hearing or an independent decision by outside physicians.
“I don’t think people are able to exercise their full rights,” Racela said.
Racela said the law clearly states that the plans are responsible for medically necessary care. Still, the delays Amaya experienced were painful, potentially dangerous and ultimately more costly to the system than prompt care might have been.
Other frustrated patients turn not to lawyers, but to their local hospital emergency room, the one place that can’t turn them away. Although at least one recent report shows that ER use is down since the advent of the Affordable Care Act, Brian Johnston, an ER physician and department chair at White Memorial Medical Center in East Los Angeles, says he has seen a lot of new Medi-Cal enrollees lately.
“They can’t get appointments at their assigned clinics. They get no answer on the phone, or they can get appointments several weeks down the road, and they figure they can’t wait.”
Johnston said he’s worried that Medi-Cal recipients risk getting second class health care if insurers remain in charge and states are allowed to reduce payments to Medi-Cal providers.
At the Department of Health Care Services (DHCS), Sarah Brooks, Chief of the Managed Care Quality and Monitoring Division, takes issue with Johnston’s assessment.
“The department makes a commitment to ensure access and quality,” Brooks said. “We work hard to provide oversight.”
DHCS reports that overall the state’s Medi-Cal managed care plans rank about average compared to similar plans nationwide in quality, timeliness of care and access, according to an independent monitoring group.
Still that means that with a few exceptions, most are failing on at least some key metrics.
To measure access to care, the agency uses criteria like the percentage of children who receive primary care, the number of prenatal and post-partum care visits, cervical cancer screening rates and several measures of diabetes control.
In Los Angeles County, Health Net’s annual performance review for 2012-13, the last year for which the document is available, shows that the plan scored below the 25th percentile compared to other Medicaid managed care plans nationwide on nine of 12 measures of access to care. LA Care did better, failing on five of those measures.
“It’s something we have to work on very seriously,” said LA Care’s acting CEO John Wallace. He said that his health plan is focused on signing up new doctors to expand access to care.
Kieffer wrote that Health Net has made significant improvements since its 2012-13 performance review.
For their part, Medi-Cal beneficiaries reckon that their managed care plans fail on most measures of health care quality and access for adults, like getting needed care and how well doctors communicate, according to a DHCS annual consumer survey. Health Net and LA Care scored poorly in all categories except customer service, on which LA Care got a ranking of fair. Consumers rated children’s health care more highly, giving both plans an overall ranking of good, while still meting out failing grades for getting needed care and getting care quickly.
The federal Department of Health and Human Services Inspector General (IG) concluded that California and other states might be missing other key access problems because they aren’t looking in the right places. In a September 2014 report, the IG found that California reported only 14 violations of its access standards between 2008 and 2013.
Racela argued that number seemed too small to be believable, given the number of complaints her office receives.
By contrast, Ohio, New York and Georgia, which tested access to care by phoning doctor’s offices to ask about their participation in a health plan or about wait times for appointments, together reported 180 such violations or 77 percent of those that were reported nationwide.
The IG recommends that states conduct the same sort of secret shopper calls that Ohio, New York and Georgia do, and suggests that the Centers for Medicare and Medicaid Services require that they do so. The report also notes that CMS does little to ensure that access standards are met, and recommends that it strengthen its oversight and work with states to identify and solve access issues.
“2014 was a really rocky year in getting people eligible,” Racela said. “There is so much chaos you can expect with a brand new system. But many long-time Medi-Cal beneficiaries were harmed in the process.”
At the Sacramento-based consumer group Health Access, executive director Anthony Wright stressed that the system’s problems can be addressed.
But the accountability and additional money that he said the system needs to right itself could be a long time in coming.