Program Review: The Good, Bad and Ugly of the Duals Demonstration Project

The enrollment process was disastrous. Yet once in, patient satisfaction levels hit 80%.

That’s a quick summary of a new review of California’s efforts to steer its most expensive patients into managed care.

At the behest of the federal government, in 2014 California launched a money-saving initiative to move its so-called “dual eligibles” – typically poor, older and chronically sick patients who qualify for services under both Medi-Cal and Medicare – into managed health programs in an effort to coordinate wildly fragmented services.

The enrollment process for the program was a failure – about half of these dual eligible patients in seven trial California counties opted out of the managed care plan they were automatically enrolled in. Another 10% opted out later.


A report from UC Berkeley and UC San Francisco affirms the enrollment failure was due largely to poor communication from the state, including form letters and confusing application packets.

Yet once successfully enrolled, an overwhelming percentage of these patients were happy with their new managed care: 8 out of 10 patients polled in focus groups held last year were satisfied with the care they eventually received.

As of February 1st of this year, 124,000 dual eligibles have been enrolled in the seven pilot counties: Los Angeles, Orange, San Diego, San Mateo, Riverside, Santa Clara and San Bernardino.

There are approximately 1.1 million dual eligibles in California.

Still, getting there has been a bumpy ride.

Four letters from the state were “too brief to allow this level of decision-making” about enrollment options, according to the report. Application forms received in blue envelopes were wildly confusing. And information packets sent from the health plans were too complex or simply overwhelming for patients to understand.

Still, there was a solution: “Those who attended [information sessions] in person felt like they got their questions answered.”

When the program first launched, state officials claimed the expense of reaching out individually to the duals population was simply too high. Instead, they instituted a toll-free phone number for information. Advocacy groups roundly criticized the information provided by phone reps, saying it was both poor and contradictory.

Last year, UC Berkeley and UC San Francisco conducted 14 focus groups – 12 of them with patients who remained in the demonstration project, and two groups with patients who opted out of managed care. Most were conducted in English, with three in Spanish, and one each in Cantonese and Mandarin.

Focus group participants said once enrolled and past the early confusion phase, patients who remained in managed care were largely pleased with the care they received.

Essential to their satisfaction was continuity of care. Patients who were able to continue seeing needed physicians were satisfied; those whose services were interrupted or delayed weren’t.

The greatest complaint: the inability to access specialists.

Experiencing disruptions in care early on was often the reason beneficiaries chose to dis-enroll from the program,” summarized the report.

The highest praise was reserved for new, easier access to behavioral health services. A key ingredient to the demonstration project is combining physical and behavioral health under a single managed care umbrella.

Other benefits of the program cited included simplified health insurance, a single help line, lower out-of-pocket expenses, and easier access to medications, equipment and hospital visits.

The report includes a summary and list of recommendations for moving forward.

Hopes are that the program – called the Coordinated Care Initiative – will eventually blanket California to include all 1.1 million dual eligibles.

California is one of 12 states across the country participating in the dual demonstrations project, which was launched by the federal Centers for Medicare and Medicaid Services. (Medi-Cal is California’s version of Medicaid.)

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