Dual Eligibles a Tricky Population To Manage

The state Department of Health Care Services wants to integrate care for about 1.1 million dual eligibles in California — people eligible for both Medicare and Medi-Cal services — by moving them to managed care plans.

“These two insurance programs don’t necessarily work well together,” according to Neal Adams, deputy director of the California Institute for Mental Health. “The benefit design is not equal across all platforms.”

Adams was part of a stakeholder summit convened last week by DHCS to discuss the dual eligible demonstration project. It was the first of three stakeholder meetings this month. Others are scheduled Dec. 12 in San Francisco and Dec. 15 in Los Angeles.

Last week’s forum focused on mental health and substance use issues among dual eligibles. About 52% of the dual eligibles have some kind of mental health diagnosis, Adams said.

The idea of the move to managed care is “to decrease fragmentation and increase coordination,” to offer better health care for duals at a cheaper price to the state, according to Adams. “But we need to make sure we simplify rather than complexify,” he said. “I made that word up (‘complexify’), but I am sometimes amazed at how complex and complicated we make things. And we really need to make sure a rise in efficiency doesn’t mean a drop in quality.”

That’s why the state is holding these stakeholder meetings, DHCS Director Toby Douglas said. “When you have county-administered mental health and substance use programs, it becomes more complicated in terms of funding and how to make it all work in a national, state and local level,” Douglas said. “We are trying to create as many meetings as possible to get as much input as we can.”

Diane Van Maren, a consultant with the state’s Senate budget and fiscal review committee, said given the complexity and confusion surrounding mental health funding in California, and the impending transfer of Medi-Cal-related benefits from the Department of Mental Health to DHCS, officials at DHCS need to come up with a better budgetary plan.

“What I’m concerned about is, [DHCS] needs to do a business plan regarding mental health services,” Van Maren said. “There are a multitude of issues in Department of Mental Health, and we won’t have that department [dealing with these issues] in July. There needs to be a focused effort and a coordinated effort, and right now there’s a little confusion going on with provision of services.”

According to Marvin Southard, director of the Los Angeles County Department of Mental Health, how federal, state and county requirements and funding will mesh is the biggest remaining concern in this project.

“What we haven’t worked out yet,” Southard said, “is what the financial model will be.”

Shifts to an integrated care model could be a huge boon to California’s health services beneficiaries, Southard said.

“In California, we have a wonderful opportunity to add to the foundation of what we’ve already done,” Southard said. “But so far, what we’ve done has tended to be projects and pilots. It’s time to go beyond projects, to a system.”

The state has the authority to run four county-based pilot programs to iron out the details in advance of a bigger duals conversion at some later date. Douglas said he hopes to have an outline of tenets of the demonstration project completed this month. “Our goal is to have draft of design criteria by the end of the year for public review,” Douglas said.

Douglas and DHCS are working closely with CMS, according to Melanie Bella, director of the CMS Federal Coordinated Health Care Office. Bella was at last week’s stakeholder meeting and said she would attend the next two, as well.

“This is about financial alignment,” Bella said. “It’s about people, but … the finances are not aligned. … We want to see more people in these [integrated] systems of care.”

The Dec. 12 meeting in San Francisco will focus on consumer protections in the demonstration project; the Dec. 15 meeting in Los Angeles will look at long-term care issues.  

Related Topics

Capitol Desk Medi-Cal Medicare Mental Health