Proposed Medi-Cal, Medicare partnership causing local confusion

*This article was originally published in the Viễn Đông Daily News on May 14, 2012. It was written by Vanessa White.

ORANGE, California—Orange County is among the first four California counties chosen to participate in a proposed demonstration project expected to integrate care for lower-income seniors and people considered to be disabled.

People eligible under both the state’s Medi-Cal program and the federal Medicare program, living in Orange County (OC), Los Angeles, San Diego, and San Mateo counties, could have coordinated care and services beginning on 1 January 2013, pending federal approval. The Viễn Đông has learned that California is among 15 others states that could participate in the proposed program.

Also part of Governor Jerry Brown’s Coordinated Care Initiative (CCI), the proposed project could include 10 other California counties aiming to improve health outcomes, promote more efficient health care, and allow more beneficiaries to stay in their homes and communities for as long as possible, according to an April 2012 California Department of Health Care Services (DHCS) press release about the project.

“Currently, most dual eligible beneficiaries access services through a complex system of disconnected programs that often leads to beneficiary confusion, delayed care, poor care coordination, inappropriate utilization and unnecessary costs, issues we are addressing with this proposal,” DHCS Director Toby Douglas was quoted in the press release. “The goal is to design a seamless system that helps dual eligible beneficiaries get the health care services they need and improve health outcomes in a more fiscally efficient manner.”

California has more than 1 million people enrolled in both Medicare and Medi-Cal, according to the press release, which adds that these people are among California’s “highest-need and highest-cost users of health care services” and account for nearly 25 percent of Medi-Cal spending.

Funded through the Patient Protection and Affordable Care Act (ACA), which is pending a U.S. Supreme Court decision on its constitutionality, the proposed project is expected to save California more than $678 million during the fiscal year (FY) 2012-2013 and $1 billion in FY 2013-2014.

“We will build upon California’s existing structure of managed care health plans, county mental health programs and home- and community-based social services to achieve the financial and service integration necessary to accomplish this goal,” Mr. Douglas was quoted.

CalOptima managed care plans

Under the proposed project, OC’s public health plan, CalOptima, would receive a combined monthly payment from Medicare and Medi-Cal to provide their enrollees all needed services, according to the DHCS press release. Beneficiaries would have a single health plan membership card and one care team that will help coordinate their services.

All medical and long-term services and supports are expected to be integrated as managed care benefits, the press release continues, though adds that Medicare beneficiaries who do not wish to participate in the proposed dual eligibility project could opt out. However, beneficiaries who do not choose to opt out by 1 January 2013 would be phased-in throughout 2013.

Garden Grove’s Tran Pharmacy Pharmacist Thư-Hằng Trần told the Viễn Đông in a 12 May 2012 phone interview that beneficiaries will receive notices in the mail, informing them of the proposed changes in September 2012. Until then, she added, beneficiaries are not required to sign any forms regarding the proposed project.

Pharmacist Trần continued, saying that some doctors will try and have been trying to mislead their Medicare patients, telling them that they must fill out an “opt out” form right away. Really, she adds, the doctors are having their patients fill out managed care applications because doctors tend to benefit from that type of plan.

“I don’t like the way they lie to the patients,” she said. “It’s totally wrong.”

Under managed care, doctors receive a single fixed payment of $120-130 monthly, even if the patient does not visit the doctor, Pharmacist Trần continued. If a patient is healthy, doctors typically try to convince them to enroll into a managed care plan because the patient rarely visits and doctors profit by doing the least amount of work.

Pharmacist Trần said that she generally likes the idea of managed care plans if doctors adequately manage their patients’ care, though she has a problem when doctors, and even patients, abuse the system.

“Be careful,” she said.