Coordinating Health Care for California's 'Dual Eligibles'

Posted on 04 February 2014

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By Viji Sundaram

Seventy-four year old Willie Posey has his hands full keeping up with his own health care needs, which include diabetes, a bad knee and neurological problems. On top of that, he also drives his 87-year-old sister to the hospital for her dialysis treatment.

Posey's income barely tops $15,000 a year, combining Social Security payments with $400 a month as his sister's caregiver, and another $400 a month as a facilitator for recovering drug addicts. Both he and his sister qualify for Medi-Cal, California's name for Medicaid, the insurance program for low-income people. They are also enrolled in Medicare, the federal insurance program for elders and people with disabilities. Since they qualify for both programs, they are known as dual eligibles.

He and his stister are part of a national experiment involving multiple states to find better ways to coordinate care for dual eligibles under the Affordable Care Act. Health care providers and policymakers are watching the Golden State's new Cal MediConnect program closely as one of the biggest and most complicated efforts in the nation.

Posey says his part-time jobs and his volunteer work keep him cheerful. His biggest challenge is constantly having to juggle between a myriad of providers, some covered by Medi-Cal and others by Medicare. He has been delaying getting his knee replaced, even though it has become a bone-on-bone situation.

“If I did that, who will take my sister to the hospital,” he asks?

Such balancing acts turn out to be costly: Dual eligibles are estimated to be the most expensive demographic in the health care system. It leads to poor continuity of care and preventable health problems, note many health care advocates, even forcing some who would otherwise prefer to stay in their homes to enter nursing homes.

"Lack of coordination is a huge problem," says Wendy Peterson, director of the Senior Services Coalition of Alameda County. "When you are trying to manage your health care, you have a lot of pieces to juggle."

Dual eligibles also experience high rates of mental illness and chronic health conditions, physical disabilities, a low literacy rate and even language barriers, adds Aileen Harper, executive director of the Los Angeles-based Center for Health Care Rights. "Some of them have no one to make decisions for them.”

Target counties to launch coordinated care program

As of April 1, dual eligibles like Posey who live in five California counties -- San Mateo, Riverside, San Bernardino, Los Angeles and San Diego -- will be able to enroll in the new Cal MediConnect, pilot program created by the Coordinated Care Initiative. Two more counties will launch their programs July 1. The goal is to give patients a seamless heath care delivery experience through health plans that coordinate fragmented treatment and support systems historically managed separately by the two programs.

California has an estimated 1.1 million dual eligibles in the target counties, of whom roughly 485,000 are likely to be enrolled in the pilot program. According to the California Department of Health Services (DHCS), 30 percent of the CCI population in those eight counties is non-Hispanic white; 23 percent Asian American and 10 percent African American.

The state has begun sending out letters to dual eligibles in the target counties notifying them of the upcoming changes and reassuring them that, among other things, the Cal MediConnect plan will let them "keep your Medicare and Medi-Cal benefits with no extra costs." It also informs them they will get a full range of coordinated services, including medical and acute care, in-home support and long-term care so they can age in place, instead of ending up in a nursing home.

Michelle Rousey of Oakland is a good example of that. The 43-year-old woman had led a very active life until an illness brought on a disability and put her in a wheelchair and on Medicare at the age of 35. Undeterred, Roussey became active in the community, serving on the Public Authority Advisory Board for In-Home Support Services (IHSS) for Alameda County and a member of the Alameda County’s Paratransit Advisory and Planning Committee. “I’m lucky because I’m living in my community in my own place,” said Roussey, a dual eligible. “I live independently with help from IHSS.”

Streamlining communication channels

One of the breakthroughs Cal MediConnect will also make is streamlining communication channels between health care providers and home caregivers. Once the program is under way, caregivers will have an easier time getting information from their patient’s doctor about such things as when to give pills to what side effects to look for to what constitutes an emergency.

"The right hand will know what the left hand is doing," Peterson says.

Senior health care advocates are optimistic about the program, but some voice concerns about the disruption the enrollment process itself could cause. Amber Cutler, a staff attorney for the National Senior Citizens Law Center (NSCLC) in Los Angeles, worries that some dual eligibles may not be able to read and understand the materials sent to them and whether there will be enough counselors available to help them "make an informed choice" between health plans.

Cost Savings

One benefit of Cal MediConnect will be cost savings through coordinated care. Jane Ogle, DHCS deputy director, says there will be a cost savings right from the first year, "with greater savings in the second and third year."

But Cutler questions whether the savings will happen to the extent the state anticipates.

"Savings will not be there at the outset, but maybe over time," she notes, adding: "Savings shouldn't be a factor anyway. Seniors get to stay in the community longer, and that should be the only goal."

Because San Mateo County "has successfully coordinated health care for 60 percent of Medicare-Medi-Cal enrollees since 2006,” according to Health Plan of San Mateo’s (HPSM) executive director Maya Altman, so transitioning the 4,500 people who will be eligible to enroll in Cal MediConnect should be smooth.

While the county of San Mateo will offer only one health plan -- HPSM -- six other counties in Cal MediConnect will each offer two health plans, with San Diego offering four.

In counties where more than one health plan is offered, enrollees will want to see whether their current health care providers are included in the plan. "If they are not, they can ask that their doctor be included," Peterson says.

Patients can retain doctors in current plans

Department of Health Care Services spokesman Anthony Cava notes that enrollees can retain their doctors in their current Medicare plan for up to six months and those in their Medi-Cal services for up to 12 months, provided they meet certain criteria.

An ombudsman program will be available in each county for one-on-one help to file an appeal or complaint.

Such a program might have helped Posey appeal his denial of hand surgery by Highland Hospital several months ago. He says that while the neurosurgeon there was ready to operate on him, his support staff refused because of the kind of health insurance he had.

If his sister enrolls as well, she will be able to continue having him as her in-home service provider.

Posey hopes the enrollment in Cal MediConnect will allow him not only to get hand surgery but also a knee replacement so he can continue living an active life.

This article was originally published at New America Media.