The California version of Medicaid, called Medi-Cal, will mandate the enrollment of about 400,000 of its patients in a state-sponsored managed-care plan over the next year.
The plan, designed to help the state cope with rising Medicaid costs, will effect Medi-Cal patients in San Francisco and fifteen other counties. California obtained a waiver from the U.S. Department of Health and Human Services in November 2010 to make the move, which local officials say will save the state approximately $365 million a year.
Other States Consider Managed Care
John Graham, director of health care policy studies at the Pacific Research Institute, said managed care in Medicaid is one method states are considering in order to save costs while increasing access.
“It’s a good idea. Traditional Medicaid fee for service is ineffective, because rates are too low, and the government bureaucrats—federal, state, and county—are not capable of determining the correct price or fee to pay for service,” Graham said. “So we are seeing decreasing access to doctors and medical services for Medicaid recipients.”
Graham says managed care solves some problems within Medicaid, but hardly all of them.
“The advantage to managed care is that the government gets out of price-fixing. Now the devil is in the details, so states are going to have to be sure they have a contract with a managed care provider in a transparent way so that the taxpayers can see who bears what degree of risk in that contract,” Graham said.
Could Improve Care
Managed care could hold promise for improving Medicaid’s outcomes, which lag far behind those of Medicare and private insurance. Research conducted by the American Action Forum’s Michael Ramlet and Carey Laferty found California’s limited experience with managed care in the past decreased hospital admissions for Medicaid enrollees with asthma, and increased the number of diabetics obtaining recommended eye exams over a five-year period.
Graham suggests more consumer-focused solutions could improve these outcomes even further.
“One thing we’re not seeing enough of in Medicaid managed care is consumer-directed care. There are no grounds to say that we should not have a managed care piece for chronically ill people, but you should also have a consumer-directed piece by which the consumer controls some of his own money, and decides how and where to spend that money,” Graham said.
“Medicaid managed care is not a panacea, but if you can get the contract negotiated so the risk-bearing is fair, and if you give some money to the individual, then you can get some leverage,” he added.
By: Loren Heal
Judd Matsunaga of Elder Law Services is a qualified attorney who has helped hundreds of California residents with Medi-Cal Planning. Mr. Matsunaga can be reached for a free consultation by calling 1-800 403-6078.
Nursing homes, ambulance companies, doctors, hospitals, home health care workers and about 100,000 consumers may see their world tilt on Friday when the Medi-Cal insurance system for low-income people transforms into a locally run HMO.
In the works since a 2005 state mandate, the change means a state-conducted system becomes a locally run network with an annual budget of about $300 million. It means as many as about 50,000 Medi-Cal members who haven’t chosen their doctors will be assigned to primary care physicians who will coordinate their care.
Many health care providers worry the change could mean less money and more problems in getting it. But leaders of the transformation say pairing each patient with a clinic or doctor’s office that serves as a medical home means people will be guided to the care they need rather than struggling to find doctors on their own or delaying care until they need an emergency room. State officials said the managed care system will eventually cost as much as 10 percent less than the current system.
“Ultimately, it will improve access to care and outcomes of care and it will reduce the taxpayers’ burden,” said Earl Greenia, CEO of the new system, the Gold Coast Health Plan.
The switch will be thrown Friday. People who qualify for Medi-Cal for doctors appointments, prescription drugs, home health care and other services will be covered by the new plan. Their complaints and concerns will be answered by a 42-person call center in Lexington, Ky.
As of last Friday, about 15,000 people on Medi-Cal had sent in their paperwork choosing a primary care doctor. As many as 30,000 people covered by both Medi-Cal and the federal Medicare program don’t have to submit a new choice.
That means about 55,000 people need to make the selection or they will be assigned to a physician.
“Fifty-five thousand is a big number,” said Dr. Robert Gonzalez, director of the Ventura County, Calif., Health Care Agency, noting people will still be able to choose doctors after Friday. “I believe there’s going to be a lot of settling out over the first two or three months of the program.”
Some observers predict varying levels of chaos with people showing up at the wrong doctor’s office or being told their specialists are no longer covered by the plan. They worry low reimbursement rates mean relatively few patients will see private doctors, meaning more pressure on facilities designed to serve low-income patients.
“When the dust settles it will actually be beneficial for the patients mainly because it will force them to have coordinated care,” said Dr. William Goldie, a pediatric neurologist at Ventura County Medical Center. “Getting to that level is going to be painful and chaotic.”
Gold Coast Health Plan leaders say they expect challenges, not chaos. They say a two-month grace period should mean patients won’t be turned away even if they show up at the wrong doctor. Providers say the same thing.
“We’ll take care of patients and hope that things get sorted out equitably after the fact,” said Mike Lurie, vice president of planning and managed care at Community Memorial Health System in Ventura.
With a few exceptions like group homes for the developmentally disabled, the new plan affects every aspect of health care received by people in Medi-Cal. That means it impacts ambulance companies, hospice care, nursing homes, home health care, outpatient centers and X-ray imaging sites.
“I’m totally confused at this point. Oh, man,” said Dave Merkley, nursing home administrator at Glenwood Care Center in Oxnard, Calif., a few hours after a Thursday conference call designed to end his confusion. He worries a new system could mean delays in the approvals needed for a nursing home to accept new patients. Gold Coast administrators say they hope to deliver the authorizations within one day.
Others expressed little angst.
“I don’t think it’s really going to change anything,” said Wynne Schumacher, director of business development at LifeLine Medical Transport ambulance company in Ventura. “The only thing that will change is where we send our claims.”
By TOM KISKEN
(Tom Kisen is a reporter fort the Ventura County Star in California.)
Judd Matsunaga of Elder Law Services is a qualified attorney who has helped hundreds of California residents with Medi-Cal Planning. Mr. Matsunaga can be reached for a free consultation by calling 1-800 403-6078.