Clashing Views of Transition for Seniors, Disabled

Either the state’s transition to managed care is going great, or it’s a confusing mess.

That would depend on who’s talking. At a joint oversight hearing last week, convened by the Senate and the Assembly committees on health, government officials outlined a generally positive picture for the effort to move Medi-Cal seniors and people with disabilities (SPDs) from Medi-Cal fee-for-service to managed care.

“The transition of seniors and people with disabilities into managed care is part of the triple mandate from [the federal] HHS,” according to Jane Ogle, deputy director at the Department of Health Care Services. “Better health, better quality and more cost-effective care.”

DHCS has been working on the transition since June, so the hearing was a chance to check in on how that process is going, according to legislators.

“Overall, we think the process is working,” Athena Chapman of DHCS said.

Advocates begged to differ.

“Eight months into the implementation, our clients are really struggling with this process,” Katie Murphy of Neighborhood Legal Services of Los Angeles County said. “This is the most confusing implementation of a health policy in California in over a decade.”

In particular, she said, the exemption provision that allows fee-for-service patients to keep their non-contracted physician for a year is a provision that is extremely difficult for patients to work out, even with the assistance of legal services.

“There does feel like there is a refusal [by the state] to fix problems at a systemic level,” Murphy said. As a result, she said, the fragile SPD population — with its multiple-condition, multiple-medication, multiple-physician dynamic — has already been hurt by a lack of care and by non-transference of health record information.

“There are people missing care,” she said. “Missing dialysis, missing surgeries, medications, because the transition has been very difficult.”

Howard Kahn, CEO of L.A. Care Health Plan in Los Angeles, said that he’s found that providers and insurers are generally in favor of a move to managed care but that the state just hasn’t had that long to implement it yet.

“There are bumps in the road in terms of implementation. These things never happen without bumps,” Kahn said. “We’ve been talking about this stuff for years, and then the state has six months to do it.”

The patients are challenging, Kahn said — for the state, and also for providers and insurers. “All of them are medically needy, many with mental illness, many of them homeless,” he said, “so they have tremendous needs, and they are extremely difficult to reach.”

The biggest improvement, he said, would be to lower the default rate — the number of patients who don’t choose a managed care plan but are mandatorily moved into one. That default rate is hovering at about 70%, several advocates said. DHCS has started using a statistical measurement known as “linkage” that takes into consideration situations in which patients see at least one of the providers they’ve seen in the past.

The linkage statistic doesn’t work well for these patients, according to advocates, since they have so many providers.

Several providers suggested slowing down the implementation process a bit, trying to iron out the details of data gathering and transfer so that more health assessments can be completed.

Providers also had many issues with the implementation so far.

“I’m told, and I hear again today, these data [on patients’ health records] are provided in advance. If so, it’s not getting down to our level,” according to Gil Simon, director of the Sacramento Family Medical Clinics. “We haven’t seen a single one.”

There’s a disconnect, he said, between what is required and what can be done with this particularly fragile population. “The goal is to get the information ahead of time, so we can do a health assessment. But we can’t do that. And since anywhere from 30% to 50% of these new SPDs have serious mental health issues, that makes it more difficult. The state needs to align their expectations with the realities of caring for this population.”

Assembly member Richard Pan (D-Sacramento) wanted DHCS to focus a little more attention on monitoring. “We can’t just go on complaints, that’s not good enough,” Pan said. “To me, I’m concerned about the level of oversight, to make sure these patients get the care they need.”

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Capitol Desk Insurance Medi-Cal The Health Law