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State takes step to shift some of poorest, sickest to managed care

California officials say L.A. and Orange counties will be among the first where people enrolled in both Medicare and Medi-Cal will be moved over. Activists say the state is moving too fast.

April 05, 2012|By Anna Gorman, Los Angeles Times

California is beginning the process of shifting 1.1 million of the state's sickest and poorest patients into managed care, which healthcare officials say will cut costs and improve treatment.

The move is part of a broader state plan to continue moving residents with publicly funded health coverage into managed care, prompting concerns among critics who fear that patients could lose their current doctors.

State officials announced Wednesday that Los Angeles, Orange, San Diego and San Mateo will be the first counties to provide managed care to the patients, who are enrolled in both the federally run Medicare and the state-federal Medi-Cal program.

Many of the patients, known as "dual eligibles," suffer such chronic maladies as cerebral palsy, Alzheimer's disease and multiple sclerosis and frequently bounce between hospitals and nursing homes. The managed care is projected to save the state $679 million in the next fiscal year and $1 billion the following year.

"The system that we have today is very complex, confusing and costly," said Toby Douglas, director of the state Department of Health Care Services. The new system will result in better care and will "use our tax dollars more effectively," he said.

Patient advocates agree that more coordinated care is necessary but say the state is moving too quickly.

"If the state wants to do this right, it needs to slow down," said Deborah Doctor, a legislative advocate for Disability Rights California. "There is just tons of unanswered questions about how this is going to work."

The state expects to begin notifying beneficiaries in the fall and start the three-year project in January, enrolling patients over the course of the first year. Health officials eventually plan to expand the program to six more counties: San Bernardino, Riverside, Santa Clara, Contra Costa, Alameda and Sacramento. About 750,000 of the dual eligibles are in those and the first five counties.

Under managed care, a health plan coordinates all of a patient's care, both medical and social. That may include medical treatment, mental health counseling and social services, such as in-home help. Instead of providers getting paid based on the number of services they provide, the health plan will be in charge of both financing and delivering care.

Experts say that could keep more patients in their homes, reduce duplication of tests and help avoid unnecessary trips to nursing homes and emergency rooms.

In Los Angeles County, the two plans that will be managing the roughly 375,000 local dual eligibles are L.A. Care and Health Net.

Douglas said dual eligible patients sometimes fall through the cracks because they have to navigate through a variety of disconnected public programs. "Now is the time to change that," he said.

Last year, the state began moving a similar population into managed care — about 350,000 low-income seniors and people with disabilities who are covered by Medi-Cal but not Medicare because they don't meet the age or other requirements.

Advocates said that transition has been rife with problems. "Until those problems are solved, it doesn't make sense for us to go ahead with a population that has even more complicated needs," Doctor said.

The state didn't put into place adequate protections for the most vulnerable people and made it virtually impossible for people to be exempted from managed care, said Katie Murphy, managing attorney at Neighborhood Legal Services.

She cited one patient who was about to have surgery following a gunshot wound when she was put into managed care, causing her to miss her surgery and go without treatment or medication for six months.

"It can work, but they have to recognize that one size does not fit all," Murphy said. "They have been loath to do that."

Douglas said that this has been a "very challenging" transition and that his department is working closely with various organizations to ensure that there is enough outreach and that there aren't disruptions in treatment.

Deborah Kujavski, who has severe diabetes and has had a kidney transplant, said she is among the Medi-Cal recipients who received notice that she would be moved to managed care. She worried that she would lose her doctors and that she might not get her medications in time.

"I am really terrified of what is going to happen," said Kujavski, 53, who lives in Norwalk. "I am never going to get a team of doctors like I have now."

anna.gorman@latimes.com

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