State health officials thought they had an elegant solution to a thorny problem.
One of the most medically fragile populations in the state is the estimated 1 million Californians who are dually eligible for benefits under both Medicare and Medi-Cal. Many, if not most of those people have multiple health conditions, multiple medications and multiple providers, they use a lot of health care services and often have care that’s fragmented and siloed.
The state’s idea was relatively simple: pool the money from the two programs and start coordinating all of the varied care that those dual eligibles receive. That seven-county pilot effort is called Cal MediConnect, and it’s part of the state’s Coordinated Care Initiative.
The new program could cut out duplicative services, make sure duals get all of the services they’re entitled to, improve communication between providers and raise the overall levels for quality of care.
Who wouldn’t want better care and more services?
Well, about 69% of the duals in the seven demonstration counties, that’s who.
Opt Outs and Disenrollees
In the November 2015 enrollment update for Cal MediConnect, the state reported a 45% opt-out rate, and another 24% enrolled and then decided to drop out of the program.
Many disenrollees had been signed up for Cal MediConnect automatically, through passive enrollment, meaning state enrolled them and they had the option to drop out once in the program. Many of them have.
The opt-out number is what has most surprised state health officials. They had estimated an upper limit of about one-third opt outs, and it’s been much higher than that.
Carrie Graham’s job is to find out what’s happening with Cal MediConnect — from figuring out why people are opting out to understanding what enrollees like or don’t like about the program once they’re in it.
Graham is assistant director of research at the UC-Berkeley School of Public Health. She has run a series of 16 focus groups to get at some of the questions around Cal MediConnect. This month she launched an extensive phone survey of 2,100 dually eligible Californians to delve more deeply into possible answers and solutions. The project, being conducted by a team of researchers at UC-San Francisco and UC-Berkeley, is funded by the SCAN Foundation.
Two of the guesses about why people are opting out of Cal MediConnect in higher numbers were not borne out by talking to dual eligibles on both sides of the enrollment coin, Graham said.
It’s not that duals are just wary of change as many people thought, she said, and it does not seem to be that providers are instructing patients to opt out.
“That’s something we saw pretty clearly in the focus groups,” Graham said. “People did not say they had been told to opt out by providers. … And our results show they did not try to get away from change for no reason. They have good reasons. Many of them have worked to get to a certain place where they’re getting good care right now. They don’t want that compromised.”
The dual eligibles in the focus groups had several other reasons for opting out, Graham said:
- One or more of their doctors were not listed in Cal MediConnect’s provider directory and people didn’t want to lose their doctor;
- A medication or some kind of durable medical goods were not listed in the benefits package, and people couldn’t afford to have trouble with those things; and
- Many people didn’t understand what extra services and supports are provided by enrolling in Cal MediConnect, such as transportation and care coordination.
Also, Graham said, some of the focus group participants who did enroll in Cal MediConnect had some difficulties in the initial transition. Graham said the satisfaction with care increased for those who enrolled in Cal MediConnect, but that those hiccups experienced in the transition might deter a lot of duals from remaining in the program.
“Most [of those who opted out] had an incident or disruption early on, like they learned they wouldn’t get a certain medication,” Graham said. “For these people with a lot of medical needs, they’ve spent a long time creating a network, so they’re more reticent to change it.”
Switching one of their providers or having trouble getting some kind of durable medical goods or one of their medications means more to elderly duals with multiple health conditions, she said.
“Things like that can be devastating to dual eligibles,” Graham said. “People can look at the provider networks and see a doctor isn’t on it, or look up benefits down to things like wheelchair repair, they can look into these things. And if there’s some kind of disruption, even if it’s for a short time, that time might be too long for people with complex medical needs.”
One of striking findings, Graham said, was the lack of knowledge among the duals about Cal MediConnect’s other benefits.
“Many were [unaware of] what Cal MediConnect can do for them,” Graham said. “They didn’t know about the dental benefits, for instance, and they didn’t understand that transportation can be provided.”
Beyond the Opt-Out Issue
Graham said much of the focus directed toward the Cal MediConnect program has been on the number of opt outs, but getting dual eligibles to understand what’s actually being offered to them is much more important, she said.
“Some people are certainly getting good care now, but there is something to be said for bringing the systems together,” she said. “There is a benefit to integrating the system.”
Some of those in the focus groups who had enrolled in the program were delighted, for instance, that their doctors started talking to each other for the first time.
“The problem with the narrative so far is its almost exclusive focus on the problem of opt outs,” Graham said. “The other part of the story, which is how Cal MediConnect has impacted the care of duals who enrolled in the program, hasn’t gotten enough attention.”
Graham said part of her research project is to evaluate the health plans’ participation in Cal MediConnect. She said she has been enormously impressed with the level of commitment to keeping people home where they want to be, and out of nursing homes and other institutional care.
“We know from our research so far that the health plans have made great progress in designing new systems to promote home and community-based services,” Graham said. “The biggest part of this is the integration of long-term services and supports.”
Under Cal MediConnect, she said, you have one managed care plan paying for home care as well as paying for nursing care — and given that choice, the health plans would rather go the less-expensive route of home and community-based care.
“So health plans now have a financial incentive to do that,” Graham said, to set up innovative ways to help duals remain independent and at home.
“They may pay for ramps, for home care, for new appliances,” Graham said, “all of the things that help people stay in their homes.”
The focus group and health plan portions of the research are winding up, Graham said. The next stage is the extensive phone survey of dual eligibles, which should have preliminary results by mid-February.