CALOPTIMA: Orange County HMO System Working
Sunday's Los Angeles Times/Orange County Edition profiled CalOPTIMA, the county's "cutting-edge, HMO-type health system for the poor and disabled." It was started three years ago as part of the "state mandate to shift the urban poor to managed care" and has since replaced the Medi-Cal system in the county. The Times reports that CalOPTIMA recovered from "a rocky beginning" and "is winning increasingly favorable reviews from patients and doctors." CalOPTIMA is the nation's largest "county-organized health system" where "government funds for public beneficiaries are funneled to a single agency." Approximately 210,000 people are enrolled in CalOPTIMA, 56,000 of whom are elderly, blind or disabled. The enrollees receive their care through 17 health plans that subcontract with CalOPTIMA, including five commercial HMOs and 12 physician/hospital groups that contract directly with CalOPTIMA to care for the patients who don't have an HMO.
Room For Improvement
Mary Dewane, CEO of CalOPTIMA, "says the agency ... still needs to improve," but that it has "laid the foundation" for an effective program. The Times reports that CalOPTIMA has improved since its inception, adding over 3,000 doctors and 2,000 specialists to the program since 1993 and providing better access for the beneficiaries. Another "key" to CalOPTIMA's "improved access," the Times reports, is that its reimbursement rates "match those of private HMOs," making doctors and medical groups vie for its business. CalOPTIMA has helped to cut emergency room visits "almost in half," according to Dr. Stephen Groth of the Society of Orange County Emergency Physicians. "Before, we saw large numbers of Medi-Cal patients with minor problems ... colds, fevers, rashes -- problems that are easy to take care of in the primary care setting. Since CalOPTIMA, we have seen virtually none of those minor, elective, walk-in type of problems." The Times reports that the number of "patient days at the county's nine busiest hospitals" was also reduced because of CalOPTIMA, from over 138,000 in 1993 to a little over 73,000 in 1997.
However, the Times reports that it is still unclear whether CalOPTIMA has actually improved the quality of care for the county's enrollees. "We don't have enough data to say that where the rubber meets the road, where the provider takes care of the patient, they are giving the appropriate care in a timely manner," said Dr. Hugh Stallworth, the county's director of public health. But even those who criticize CalOPTIMA "say the problem isn't so much the agency itself but the weakness of all managed care systems." Patient advocate Rhys Burchill said, "I think managed care works fine for people who are well, but for people who have unique and chronic needs, it can present many barriers to treatment and supplies." Dewane said CalOPTIMA has a tough road ahead because it handles a larger percentage of disabled enrollees than other HMOs, but that it's better than the old fee-for-service program under Medi-Cal. "The disabled community is a complex one to serve and present the knottiest problems ... but CalOPTIMA has designed a program that better serves all of the disabled community," she said (Warren, 10/27).