Next month, state health officials will launch a transition of rural Medi-Cal beneficiaries into Medi-Cal managed care health plans.
Medi-Cal is California’s Medicaid program.
The transition involves about 20,000 of the most frail and elderly segment of the rural Medi-Cal population — seniors and persons with disabilities, known as SPDs.
“Most of them have a disability or high levels of functional impairment,” said Carrie Graham, assistant director of research at UC-Berkeley’s Health Research for Action. “They have multiple chronic conditions, they need a lot of specialty care, they have a lot of prescriptions, they need medical equipment and supplies.”
They’re people who are on a precarious medical ledge — poor people with big medical needs, no Medicare benefits and a whisper-thin web of cobbled-together providers and services. It’s the type of population that has a hard time with transitions, Graham said.
“They’re the ones most at-risk for institutionalization,” Graham said. “For them, disruptions in care can be particularly dangerous.”
On Dec. 1, the state plans to finish its transition of 28 rural counties, moving from fee-for-service Medi-Cal into a Medi-Cal managed care system. It’s saved the toughest 20,000 patients for last.
The state has shifted beneficiaries before, but not in rural areas. The first SPD transition — about 340,000 people in 16 mostly urban counties across California — didn’t go that well, according to critics. There were many reports of disruptions in care, lack of communication and failure to transfer patient records in time for the transition.
Graham has researched that transition thoroughly and wrote a report about it.
“Overall and in general, you tend to see people actually rate their access and experience better once they’ve been in managed care for a while,” Graham said. “There were definitely transition issues at first. But we saw, retrospectively, in most areas people said it was about the same or better.”
California health officials said they’ve learned from mistakes made in previous transitions — and not just from the first SPD transition.
The state has orchestrated other managed care shifts, including:
- An eight-county demonstration project moving about 460,000 people dually eligible for Medi-Cal and Medicare into Medi-Cal managed care plans;
- Rural expansion of non-disabled adults and children in 28 counties; and
- Transition of about 860,000 kids from Healthy Families into Medi-Cal managed care.
Those efforts have mightily informed this transition, said Mari Cantwell, chief deputy director of health care programs at the Department of Health Care Services.
“We certainly have applied lessons learned,” Cantwell said.
Because the population is so frail and doesn’t tolerate disruptions well, it’s important to set up as many aspects of the transfer ahead of time as possible, Cantwell said.
“We’re making sure the health plans have data on people in advance of being enrolled in the health plans,” Cantwell said. “And we’re working to make sure there’s more clarity on the continuity-of-care provision.”
That means educating beneficiaries and providers about plans to pay for continued care, whether or not providers are in-network with health plans at the time of the transition.
“We want more clarity and a lot more noticing,” Cantwell said. “We learned from the first SPD transition we needed to send a lot more notice to people, so they know what’s happening.”
Department representatives have been doing site visits in rural areas, she said.
“We have seen a lot of people at the local level,” Cantwell said. “Our staff has been going out in rural areas to talk to people, so people understand what managed care is and what we’re doing.”
With all of that preparation done upfront, Cantwell said, the emphasis of the transition itself come Dec. 1 can be on the positive effects of having these frail patients covered by managed care plans.
“From our perspective, our managed care plans are able to provide better integrated care,” Cantwell said. “They’re doing risk assessments on everyone, to see where the ones are who need greater care.”
Cantwell said managed care can be better care.
“It’s really about improving care, that’s what this is about,” Cantwell said.
“Their health plan can help navigate the system for them,” she said. “It’s a better way to care for people.”
Immense Challenges in Rural Settings
Steve Barrow said the health care system in rural counties is precarious to begin with, so it’s especially challenging for the SPD population. Barrow is president and CEO of Advocates for Health, Economics and Development, a not-for-profit advocacy group for underserved areas, including rural California counties.
“Understanding the lessons learned doesn’t change the reality,” he said. And that reality is bleak, in terms of health care, he said.
“In rural areas, you have extreme difficulty in establishing any specialists in the first place,” Barrow said. “So saying you’re going to have a network of specialists is good, but they’re hard to come by.”
Getting specialist care from primary care providers can be dodgy, as well, he said.
“There’s a huge shortage of primary care physicians, too, in rural areas,” Barrow said. “And these are extremely complicated cases to deal with. They have multiple health issues. I mean, the landscape already is difficult for people who are healthy.”
The care currently cobbled together by people in the rural SPD population is not great, Barrow said, but that makes it even more difficult to change providers, even if those providers are similar distances away — which they may not be, Barrow said.
“They call it a safety net for a reason, it’s very thin,” he said. “It’s not like you have five specialists to choose from. In an urban setting, you have a better opportunity to find a specialist nearby. Out here, if you used to drive 60 miles to a provider, now maybe you have to drive 80 miles. And that’s a big issue out here.”
Specialist Care Could Be Pivotal
One of the keys to a successful SPD transition, Graham said, is to identify the people who are the worst-off among that population and figure out how to help them through the transition.
“We found that, when we looked at the people who were saying [their care after transition] was worse, we saw overwhelmingly, those were the ones with more functional impairment. Their experiences were more negative,” Graham said.
“There will be lots of issues at the beginning, new doctors in new places and so on,” Graham said, “but you really have to watch the people who have the most problems to begin with.”
The one factor that was a game-changer for people in the previous SPD transition, Graham said, was access to specialty care.
“Just getting in to see a specialist was a big one,” she said.
The truth is, Graham said, the fee-for-service system isn’t working for people in rural counties.
“There are so many problems now with fee-for-service Medi-Cal. I guess the question is whether it will get better or worse,” Graham said.
“And really, it can’t get much worse.”
Graham said the biggest change in the rural shift to managed care may be accountability.
“The managed care plans are required by law to provide care,” Graham said, “whereas in fee-for-service people were on their own. The big question will be, where they find the doctors, that’s the question.”
And from the point of view of a poor, disabled, multiple-condition patient who has trouble traveling to appointments, she said, “The big question will be, ‘How will I make it?’ I know there is horrible fear there. People are very concerned about the change.”
“Transitions are messy,” she said. “It may be difficult in the first few months. Much as I want that not to be true, that’s how it has been.”