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Health Plans’ Quality for Duals in Question

Seven of the eight health plans in California’s pilot project to shift dual eligibles into managed Medi-Cal have inferior quality ratings for treating Medi-Cal beneficiaries, according to a report released yesterday.  

The ambitious plan for 1.1 million Californians eligible for both Medicare and Medi-Cal benefits will start with a pilot program in four counties — Los Angeles, Orange, San Diego and San Mateo. The state hopes to expand the pilot project to as many as 10 counties, pending legislative approval.

The report from National Senior Citizens Law Center, citing the state Department of Health Care Services’ own quality assessment, shows seven plans earned a rating of 1 out of 5 stars in overall Medi-Cal performance.

The seven one-star rated plans are Cal Optima, Care 1st, Community Health Group, L.A. Care Health Plan, Health Net (in Los Angeles and San Diego) and Molina Healthcare. Health Plan of San Mateo has a three-star rating.

“Our position is that these are demonstrations, it’s a pilot project, so they should be including the best plans. They should be including the ones prepared to try new systems,” said Georgia Burke, directing attorney at the Oakland office of the National Senior Citizens Law Center, which released the report.

The duals project as it’s constituted is large, complex and deals with a fragile population, Burke said.

“It’s a massive change in the way health care services are going to be delivered, so you want to be careful and you want to do it right,” Burke said. “We think the performance ratings raise serious concerns about whether some of these plans are ready to take on that task.”

In a written statement, the Department of Health Care Services said it is aware of the quality concerns, and has incorporated that into its project guidelines.

“This process includes measures that address the known challenges described in [the] report,” Norman Williams of DHCS wrote in an email. “We selected these health plans to participate in the duals demonstration after a rigorous review that required, among other components, proof of upward trending care quality measures and local stakeholder support.”

Williams also wrote that those seven health plans with low quality ratings have all been accredited by the National Committee for Quality Assurance. “This is a widely recognized affirmation that an organization is well-managed and delivers high quality care and service,” Williams wrote.

Burke said that “rigorous” is not the word she would use.

“We have some concerns about how rigorous that review was,” Burke said.  “We’re concerned about the size and the pace of this project, and this report also raises concerns about quality going forward.”

For a pilot project, the Coordinated Care Initiative has a huge scope, Burke said — with more than half of all the state’s duals living in Los Angeles County alone. If the state gets legislative approval in the next two months to expand to 10 counties, that plan will encompass most of the 1.1 million dual-eligibles in California.

“There’s a lot of promise here, but if it’s done wrong, there could be real problems,” Burke said. “Size and scope and quality are major concerns for us. And they should be for the state, as well.”

Related Topics

Capitol Desk Medi-Cal Medicare