Michael Williams, who has cerebral palsy, has seen the same network of doctors for decades under two government health plans. But on May 1, California began an initiative that will change the way he and 460,000 other low-income patients get care.
Advocates, doctors and patients, including Williams, have concerns about the continuation of health care under the plan, which affects the elderly and those who have disabilities.
The new initiative, known as Cal MediConnect, combines two health programs into one package and puts coordination into the hands of a managed-care plan. The patients affected are called “dual eligibles,” because they are eligible for both Medi-Cal, the state’s low-income health program, and Medicare, a federal health program for those 65 and older, as well as people with disabilities.
The dual-eligible patients are, according to advocates, among the state’s most vulnerable residents due to their extensive short- and long-term health-care needs. More than half are older than 65, many are disabled and it is not unusual for them to suffer from multiple chronic illnesses or mental-health issues.
Patients concerned about access
The state will eventually roll out the plan over the next year in eight counties — Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara. In all, nearly half a million people will be affected.
Williams, a 58-year old resident of Altadena, isn’t sure he wants to be one of them. Under Cal MediConnect, he may lose access to a network of health-care providers that took him half a century to construct, including the specialist who has made his leg braces for years. They have not joined any of the managed care plans operating Cal MediConnect in L.A. County.
Starting over with new providers is a scary thought, he said.
For now he’s trying to sort through a stack of notices and booklets sent by the state that explain what steps he needs to prepare for the transition, and he’s still waiting for more.
Williams intends to meet with his doctors before deciding how to move forward. He could join Cal MediConnect and lose access to his providers. Or, he could keep his insurance as is and continue to see them, but some of the services he depends on may no longer be covered.
“I can’t tell you which way I’m going to go,” he said. “But a lot of people will be reluctant to switch because they don’t want to change.”
There is already resistance, said Aileen Harper, executive director of the Center for Health Care Rights, L.A. County’s Cal MediConnect outreach partner. For three days after the first round of notices from the state went out, the center got 50 to 75 calls a day from people asking to talk to counselors. A larger number of calls, about 100, were from people calling to say they wanted to stay with the coverage they have. If they take no action, the state will automatically assign them to a managed-care plan.
Once enrolled in Cal MediConnect, counties will allow patients to continue seeing their existing doctors for six to 12 months, but after that if the doctors don’t opt to join the program, the patients will have to find new providers.
L.A. County won’t fully launch the initiative until July 1. The results of limited and mostly voluntary trials in four other counties — Riverside, San Bernardino, San Diego and San Mateo — have left some patients and their physicians confused and upset, according to doctors and advocates.
Ted Mazer, a San Diego doctor, said patients are turning to physicians for advice, but they don’t have the answers either. “The information (the patients are) receiving is entirely inadequate,” Mazer said.
So far, 3,200 dual-eligible patients have been enrolled in San Mateo County. Another 300 are signed up in Riverside, San Bernardino and San Diego counties. The state expects to enroll at least 26,154 people in the four counties by the end of June. As of March, nearly 3,000 people in those counties had requested to opt out of the program, according to state figures.
Speed of implementation questioned
California is one of about 15 states launching a dual-eligible initiative aimed at improving care and lowering costs.
Eventually, the eight participating California counties are scheduled to enroll about 460,000 people as part of a three-year test. Then the initiative could expand to the rest of the state.
Gov. Jerry Brown originally wanted to move faster and more aggressively, in part because of the budget-saving potential of the initiative, assumptions the California Legislative Analyst has called “highly uncertain.” New budget figures will be updated in May.
Supporters hope coordinating the complex care dual-eligible patients need will lower costs, currently estimated at $350 billion a year nationwide.
Numerous advocates and provider associations say they support the goals behind Cal MediConnect. But they want the state to slow down and reconsider the size of the trial in L.A. County. The plan there is to enroll 200,000 people — about 44 percent of the county’s dual-eligible population of 460,000.
“From the provider standpoint, the complexity in the business office has been profound,” said Deborah Pacyna, public affairs director for the California Association of Health Facilities, a professional association of long-term care providers. Instead of working with Medicare and Medi-Cal to process claims, providers must now work with multiple health plans and their subcontractors, each of which have different policies, billing procedures and pre-authorization policies for services, she said.
Rocky Delgadillo, chief executive of the L.A. County Medical Association put it more bluntly. “Going so fast is not the right thing to do,” he said.
Officials say they’re ready
The state believes the plan is ready to be rolled out, in order to help streamline care and save money sooner. “We believe that the program is ready to offer quality, coordinated health care for dual eligibles,” Department of Health Care Services spokesman Anthony Cava said.
To facilitate the process, the state set up an independent ombudsman and made materials available in more than a dozen languages online and through outreach partners. Numerous oversight measures have been put in place to try to ensure that the initiative delivers on the promise of improve care, Cava said.
“Cal MediConnect represents many years of dedicated work,” he said.
The initiative has already been delayed several times. Centers for Medicare and Medicaid Services also blocked one of L.A. County’s managed-care plans, L.A. Care, from automatically enrolling patients until January 2015 because it performed poorly on Medicare’s quality assessments.
Orange County’s health plan, CalOptima, was suspended from Cal MediConnect after a federal audit found serious violations that posed a “threat to the health and safety,” according to a letter from the federal centers.
More recently, the state delayed Alameda County’s launch until January 2015 because one of its plans, Alameda Alliance for Health, didn’t have enough money in its reserves.
Santa Clara County, meanwhile, asked the state to allow it to push back Cal MediConnect automatic enrollment until January 2015. “We want to roll this out in a positive way,” James Ramoni, director of the Department of Aging and Adult Services, said.
Gary Passmore of the Congress of California Seniors, an advocacy group for seniors and people with disabilities based in Sacramento, is in favor of moving forward. But the delays were a blessing in disguise, he said.
“We’re kind of standing on the edge of a cliff looking down, hoping the parachute opens,” Passmore said.
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