California Gets Federal Nod to Coordinate Care for Most Vulnerable Patients

California Gets Federal Nod to Coordinate Care for Most Vulnerable Patients

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Photo: Arsenio I. Jimenez, MD, examines patient at Sacramento’s Molina Medical Clinic. (Courtesy of Molina Healthcare)

SACRAMENTO – California became the fifth and largest state this week to win federal approval for a new plan aimed at improving care for almost a half-million of the state’s most vulnerable patients.

Called Cal MediConnect, the new three-year demonstration program initially will enable the eight counties to pool funding and resources for so-called “dual-eligibles,” lower-income people who qualify both for federal Medicare and the federal-state Medi-Cal program for the poor (California’s name for Medicaid).

In announcing the program Wednesday in a teleconference from Sacramento, California Health and Human Services Secretary Diana Dooley, said the triple aim of Cal MediConnect is to provide enrollees with “better care, better health and at lower cost.”

Ends Checkerboard of Health Programs

With the approved federal-state agreement, eight California counties will test a new approach that supporters of low-income seniors and people with disabilities hope will better integrate and coordinate their care. The present system often makes many jump around a checkerboard of programs resulting in higher government cost, poor continuity of care and preventable health problems.

But consumer advocates, while generally hopeful that the new program will end that care fragmentation, are also raising concerns that program announced this week will not allow participating health plans and providers enough time to absorb so many additional patients by Oct. 1, when the program will start.

During Wednesday’s call and a follow-up teleconference on Thursday, Dooley and her staff outlined the benefits of the program to hundreds of “stakeholders,” such as health care plans, providers and consumer advocates.

Dooley explained that provisions of the 2010 Affordable Care Act (ACA) offer enhanced options to improve care for dual-eligibles. One is the patient-centered medical home that is designed to integrate care for various health needs.

Also, the pilot project grew out of Gov. Jerry Brown’s 2012 Coordinated Care Initiative to move low-income seniors and people with disabilities now aided by multiple state programs—adult day health care, case management and In-Home Supportive Services (IHSS)--into managed care plans.

The new eight-county pilot program will enable health care providers to go beyond coordinating those three long-term support and services programs for people with continuing care needs by also including Medicare’s coverage of hospitals, doctors and prescription drugs.

In outlining the Cal MediConnect program on Wednesday, Toby Douglas, director of the California Department of Health Care Services (CDHC), noted it was originally set to begin in March. But under the new agreement with the U.S. Centers for Medicare and Medicaid Services (CMS), the launch date was moved to October, to enable participating agencies “to talk to each other,” Douglass said, smoothing out the transition.

‘Live and Operational’ Oct. 1

Total enrollment will be capped at 456,000, Douglas said, a little less than half of California’s 1.1 million dual-eligibles. Seven in 10 are age 65 and older, and the majority are women, and about one-third are younger people with disabilities, according to the website, CalDuals.org [www.calduals.org/].

The eight demonstration-project counties are Alameda, Los Angeles, San Bernardino, San Diego, San Mateo, Santa Clara, Orange and Riverside.

During Thursday’s teleconference, CDHC Deputy Director Jane Ogle told the 600 stateholders on the line that in most of the counties the Cal MediConnect demonstration will begin enrolling dual-eligibles in August and the program. “The implementation date is Oct. 1,” she stated. Programs will have to “go live and be fully operational,” providing services on that date, she said.

A major change for dual-eligibles in California is that about 80 percent now receive care on a “fee-for-service” basis, with the fee paid by the state or federal government for each doctor, test or procedure. That makes it difficult for patients to navigate more than one system, sometimes exacerbating health conditions, according to the program’s website.

However, Ogle allayed previous widespread confusion about whether patients would be forced into health maintenance organizations (HMOs) for all of their care.

She assured stakeholders on Thursday’s teleconference that for the federal Medicare part of the Cal MediConnect program, patients can still retain their current doctor and coverage, even if it is in Medicare’s fee-for-service plan. They would not have to join a Medicare Advantage HMO.

However, those who also need the long-term services and supports under the state initiative will be shifted into managed care for those ongoing services.

The new demonstration program will enroll dual-eligibles on IHSS automatically in Cal MediConnect. However, individuals in the Community Based Adult Services program (for adults day health care), or the Multipurpose Senior Service Program (for case management) will still have to be qualified separately by the state to continue receiving those services within the pilot project.

Advocates’ Concerns

Although optimistic about the potential for Cal MediConnect to improve care, Kevin Prindiville, a staff attorney with the National Senior Citizens Law Center (NSCLC) office in Oakland, said, “There are still concern that the number of participants will be too large, and the timeline too fast.”

Prindiville served as a consumer representative on the state health department’s work group on consumer protection that helped develop the new programs. He said, “We will still push the Department of Health Services and CMS to reconsider.”

Patient advocates are worried, he explained, that Cal MediConnect is including too many beneficiaries at this point.

“We think the system should be set up with smaller groups to give the state, the plans and the providers a chance to adjust,” he said.

Even though the newly approved program cuts the original number for Los Angeles County in half—from 400,000 to 200,000 people—Prindiville said their cases will be handled by two private health plans with little experience managing their complications of long-term support and services.

He added, “We don't think any type of enrollment should begin any sooner than January 2014,” rather than this October. Moreover, he said, the state should move more slowly by starting all of the county programs with voluntary enrollments, as the other four federally approved states have done, signing up people who learn about it and are ready for the change.

But the Cal MediConnect, Prindiville said, there are different enrollment timeframes with only Los Angeles initially offering voluntary enrollment from October through the end of December. Starting in January, the state will automatically enroll others throughout 2014. The other counties must all start with automatic enrollments in October.

“Transitions can be tricky,” he emphasized. “For instance, people will want to change providers or prescription drug plans. Moving more slowly would give time for people and the system to adjust to their needs at a detailed level.”

Quality Care and Access

Prindiville said he was pleased to see that the state and CMS were receptive to requests by consumer advocates to include an ombudsman program in the final Cal MediConnect agreement. The ombudsman will investigate beneficiary complaints. State health officials and CMS are still working out the program’s details, according to CDHC’s Ogle.

Prindiville said he hopes ombudsmen will be available in each county for one-on-one help to file an appeal or complaint, such as if the quality of care is not up to a good standard.

“Assistance should be available in their county, not at an office in Sacramento,” he said. “Typical problems have been denial of services, problems finding a doctor in a plan’s network, or a person’s current provider not being on the plan.”

During Thursday’s tele-call, Ogle noted that the state’s materials would be translated into several languages listed in state law. But Prindiville, stressed, “The next step would be to ensure translation is done in the designated language by the health plans.”

“A big component of this demonstration program, Prindiville said, “is achieving state budget savings.” Health plans in Cal MediConnect will receive rate reductions from the 2013 level of 1 percent rate the first year, 2 percent the second year and 4 percent the third year.

“The major question is what kind of pressure will this put on plans? Will quality or access suffer?” he asked.

DHCS Director Douglas emphasized in a statement: “We are confident that the managed care plans we selected will make a positive impact on enrollees’ lives by coordinating care across the full continuum of services.” And he noted, “We have taken extensive measures to plan for and enforce strict quality and readiness standards.”