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OPTIMA Health Plan OK Awaited : Medicine: Agency today will select what approach it will take in creating Medi-Cal system.

October 04, 1994|LESLIE BERKMAN | TIMES STAFF WRITER

Orange County today is expected to adopt a one-of-a kind system for providing health care to its 300,000 Medi-Cal recipients.

OPTIMA, the organization creating a new managed-care system for Medi-Cal patients in the county, is trying to curb Medi-Cal's burgeoning cost in part by shifting indigents away from expensive hospital emergency rooms to an expanded pool of doctors close to their homes who can offer regular health care.

When directors of OPTIMA meet today to select a plan for the new system, they will have several options. But the agency's consultant has given the highest marks to a plan that would allow the agency to contract with both existing health maintenance organizations and new alliances of independent doctors, clinics and hospitals.

Today's decision will be "a major turning point in the development of the system," said Samuel Roth, assistant director of the Orange County Medical Assn. "It will go a long way to determining how providers wishing to contract with OPTIMA will be required to organize themselves and with whom they will be required to organize."

Orange County follows two other counties, Santa Barbara and San Mateo, which more than a decade ago assumed from the state the responsibility for providing Medi-Cal services. In addition, Solano County established its own Medi-Cal system in April and Santa Cruz County, like Orange County, will begin patient enrollment in July.

One of the early county-based Medi-Cal programs founded in Monterey County went bankrupt; state officials said it was the result of poor management, including overgenerous payment of hospitals and physicians.

But with an estimated 300,000 patients to serve and an annual budget of up to $600,000, OPTIMA will be the largest of its kind in the nation. Moreover, "OPTIMA will be the biggest health plan by far in Orange County, bigger than Kaiser," said John R. Cochran III, chief executive officer of Martin Luther Hospital in Anaheim and OPTIMA's board chairman.

Only a small number of Orange County physicians accept patients covered by Medi-Cal, which has been criticized for low reimbursement and red tape.

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In demonstrating the urgency to improve access to health care in Orange County, OPTIMA consultant Cindy Johnson has said that only 50% of Medi-Cal recipients on Aid to Families with Dependent Children in the county receive any medical services in a given year, compared to about 85% on the East Coast.

Since OPTIMA was formed last year by the Orange County Board of Supervisors, many doctors and hospitals have been waiting to learn how they can participate in the new program.

Although the switch from fee-for-service to a prepaid managed health system is not expected to be any more lucrative for doctors and hospitals, the hope is that because OPTIMA will be administered locally, it will be more hassle-free and responsive to area needs than the state-administered Medi-Cal program.

"Many providers show support for anything that will alleviate the built-in denials and retroactive denials of the system driven out of Sacramento," Roth said. "It is half the battle when you alleviate the hassle associated with trying to provide quality medical care."

OPTIMA board members face four choices today, including one that would have all Medi-Cal patients enroll in health maintenance organizations or in the few physician groups that already have created a full range of integrated medical services.

Consultants have determined HMOs would save the state the most money because they have experience controlling the use of services and would not require OPTIMA to act as a gatekeeper to prevent excessive patient referrals to specialists and excessively long hospital stays.

But there is widespread fear, especially in Latino and Asian communities, that exclusive contracting with HMOs would squeeze out the independent physicians, clinics and pharmacies that traditionally have served neighborhoods.

"The greatest fear we have in the Asian community is that foreign-born doctors who currently are serving the Asian medical population will lose their clientele," said Alan Woo, president of the Asian Pacific Health Alliance, a group of health-care advocates.

"Our physicians will not have a say within traditional HMOs, because that environment is western based with an Anglo philosophy that has traditionally discriminated against non-English-speaking doctors," he said.

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On Friday, OPTIMA's Executive Director Mary Dewane was guided through Little Saigon's clinics and pharmacies by Westminster Councilman Tony Lam, who said he wanted to show her that Vietnamese physicians are doing a fine job taking care of that population.

Lam said he wishes OPTIMA would model itself after the Medi-Cal plans of Santa Barbara and San Mateo, which will contract with solo practitioners and stand-alone clinics. This option is also before the OPTIMA board.

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