The state plans to roll out its dual eligibles demonstration project in seven California counties on April 1, affecting roughly 400,000 older Californians who qualify for both for Medicare and Medi-Cal.
Medi-Cal is California’s Medicaid program.
A pilot project of that size and scope is bound to have a number of difficulties and attendant concerns, and this project certainly is facing its share.
- The eight-county project recently became effectively a seven-county project when federal officials temporarily halted participation by CalOptima, the sole participating health plan in Orange County. CMS officials found problems with the plan’s Medicare readiness for taking on a larger share of the duals population. The state now is conducting an audit of CalOptima’s Medi-Cal readiness. Orange County has the second-largest number of duals in the state.
- The effort in Los Angeles County took a hit when CMS officials temporarily limited one health plan’s participation in the project. Los Angeles, with the largest population of duals in the state, was supposed to be served by two health plans but one of them — LA Care — is temporarily unable to automatically enroll beneficiaries because of low CMS star ratings. The state added three other health plans to the project to handle the upper limit of 200,000 duals the state is allowed to enroll in Los Angeles County.
- Concerns persist about the process for beneficiaries to opt out of the program. The state will not issue an opt-out form, instead releasing a Medi-Cal choice form, which will include an option to choose fee-for-service.
- Three counties (Riverside, San Bernardino and San Diego) will start enrolling beneficiaries one month later than planned because of delays in sending 60-day notices.
- The launch will be delayed in two other counties for other reasons. Alameda County, which has had financial problems implementing the program, is expected to launch in July; Santa Clara County, which has had technical problems, is expected to start in January 2015.
State Officials Excited by Potential
Despite the challenges, state officials are excited about finally implementing the duals demonstration project after three years of intensive stakeholder meetings and planning sessions.
“The [duals project] has so many elements in it of what we’re trying to do,” Toby Douglas, director of the Department of Health Care Services, said last week at an Insure the Uninsured Project conference.
“We’re trying to replace 50 years of building these systems, where dual-eligibles are having to navigate multiple levels to get care. We are working to create patient-centered health care.”
That kind of major change, Douglas said, not only produces a series of challenges, but it also breeds tension around the effort and implementation.
“It creates so much anxiety and so many challenges. But we need to embrace the change so we can focus on better care and better outcomes at lower cost,” Douglas said.
Rolling Out Duals Project
Jane Ogle, deputy director at DHCS, said concerns about the duals program are real but she doesn’t much like the alternative of maintaining the dysfunctional status quo.
“I think our goal has always been that integrated and coordinated care is going to be better care,” Ogle said. “The way care is delivered now does not give people the care and services they need. For 20 years, advocacy groups have been saying care is siloed and fragmented so why are we so against this now?”
The size and scope of the project — moving as many as 400,000 Californians into managed care — was a conscious decision to have a big enough project to ensure its success, Ogle said. The project was designed around a system that automatically moves eligible Californians into managed care plans in a process known as passive enrollment.
Scale is important because insurers need a large number of participants to provide a diverse risk pool, Ogle said.
“That’s why it’s passive enrollment, to make sure the plans don’t go under,” Ogle said.
Concerns About April Implementation
Karen Wrubel, a podiatrist and a member of the state’s Board of Podiatric Medicine, said the initial launch targeting almost half of the state’s one million duals doesn’t seem much like a pilot project. She pointed out that none of the 14 other states in the national demonstration project are of similar size or scope. She said the inevitable result of transitioning so many people will be that some will fail to receive the same level of care they’re getting now or they will fail to have that care paid for.
“I’ve worked in managed care for 20 years, and I’ve seen instances where people move into new health plans and suddenly they can’t see the same doctor or get the same care,” said Wrubel, whose practice is in Hawthorne, Los Angeles County.
With this high need, often cognitively impaired population gaps in coverage or payment can be dire, Wrubel said.
“We just see patients being confused and overwhelmed. No one seems to know what’s happening, even DHCS. Managed care can be an appropriate choice, but when they’re being enrolled with their passive consent, they have no way of knowing how to navigate the system,” she said.
Wrubel is concerned that many of the beneficiaries won’t know what’s happening to their coverage and will likely just show up in their providers’ facility and want to know why they can’t see that particular provider anymore.
“All of these people being switched at once, it’s going to harm people,” Wrubel said. “They show up at the doctor’s office and they can’t be seen. So they say, ‘Why can’t you see me?’ or ‘Why can’t you get paid?'”
She said that happens on a relatively regular basis in her practice. “This has happened over the years. We just expect it will happen more now,” Wrubel said.
Wrubel has three main concerns:
- LA Care, the largest health plan participating in Los Angeles County, has been excluded by federal officials from passively enrolling dual-eligibles. LA Care had a quality rating that dipped below CMS standards. So now that passive enrollment slack will be taken up by three other plans — CareMore, Care 1st and Molina Healthcare. “We haven’t met with any of these plans or gone through the vetting process for any of them,” Wrubel said. “LA Care is certainly the largest. How can they not pass the readiness review, but these others can? That makes no sense.” If adding three new health plans increases choice, Wrubel asked, “Then why wasn’t that the case in the beginning?”
- Because of the many delays — some ordered by federal officials — the transition has many start dates, further muddying the waters for beneficiaries, Wrubel said.
- The biggest issue, Wrubel said, is the process for beneficiaries to opt out of the project. CMS requires that dual-eligibles in the California demonstration have the right to remain in the current fee-for-service system and not participate in the managed care project. DHCS officials discussed either an opt-out form or an opt-out box on other forms, but instead the state will issue a form outlining beneficiaries’ choices. Wrubel and other advocates are worried the form will not adequately explain the opt-out option. Ogle and other DHCS officials said the option to not participate in the project will be clear in the choice form sent to all beneficiaries. No one ever promised there would be an opt-out form or opt-out box, they said.
‘It’s for the Beneficiaries’
Both sides said they are concerned about what’s best for dual-eligible beneficiaries.
Wrubel gave an example of a diabetic ulcer patient who has an acute problem that can flare up whenever there is a gap in health services.
“That person can end up in the emergency room, which is not the best place for that person. There is worse morbidity and worse mortality,” she said. “So they don’t really have access to care.”
But bridging that gap is just what Ogle said is the goal of the duals demonstration project in the first place.
“It goes back to the philosophical view I have, that it’s better for people fundamentally,” Ogle said.
She said she’s excited by the idea of helping so many people who have had difficulty navigating such a complex system, she said.
“I think it ought to be in all of the counties,” Ogle said.