The largest national dual eligible demonstration project is taking a belated start in California, amid concerns from patient advocates. The concern surrounding the project indicates that new managed care plans have a long way to go, both in fixing problems in the system and getting buy-in from beneficiaries.
About 450,000 Californians eligible for both Medicaid and Medicare, most of them seniors, are about to be enrolled in the state's managed care demonstration program, called Cal MediConnect.
The first of three mailed notifications to beneficiaries went out in January, and in April beneficiaries in one of the eight demonstration counties will begin passive enrollment, meaning they'll be automatically enrolled unless they opt-out.
The potential disruptiveness of the new demonstration has prompted "strong pushback" from some stakeholders, said Kathryn Kietzman, research scientist at the University of California-Los Angeles' Center for Health Policy Research, who's been tracking the evolution of the policy and led a study interviewing dozens of Medicaid-Medicare eligible-patients and their caregivers.
Six advocacy groups including the National Health Law Program and the National Senior Citizens Law Center have called for the demonstration to be suspended, arguing that communications to beneficiaries so far has been inadequate and only spurred confusion. Informational call centers aren't ready to handle an influx of questions, they claim.
The impact of Cal MediConnect
With only minor delays, though, the transition is going ahead. And with many beneficiaries currently receiving suboptimal services through a very fragmented, often unaccountable and very costly system, there's potential for both "promise and peril," UCLA's Kietzman said during a March 19 presentation.
In their study, called the HOME Project, Kietzman and her colleagues found dozens of California seniors who are at once frustrated with their current options and leery of the coming changes.
While many have had "fragmented networks of care and long-term services and supports for some time," they've also established relationships with doctors and may end up having to switch providers as a result of the demonstration.
One such senior is Angie, a 77-year-old speaking primarily Spanish with limited English, who suffers from Parkinson's, diabetes, heart disease, arthritis and osteoporosis and just concluded successful treatment for non-Hodgkin's lymphoma.
Angie came to the U.S. in the 1970s, worked as a single mother and now lives with her daughter, her paid in-home services and supports caregiver. Reimbursement for her daughter's services was cut by five hours per month.
Angie is, for now, planning to opt out of managed care precisely because it would mean she would eventually have to switch her oncologist and cardiologist (the demonstration allows enrollees to keep existing providers but only for up to six months or year, depending on the circumstances).
Angie and others like her could benefit from several aspects of the new managed care system, including access to community-based seniors programs and better transportation to and from medical appointments and recreation activities.
But as her daughter Julia told UCLA researchers: "We had trouble with transportation. I don't know if insurance covers it, because I usually end up paying for the transportation."
"Transportation for one is a big opportunity for improvement," said Jacqueline Torres, a UCLA graduate student and researcher with the HOME Project.
Communication concerns
Another big opportunity for improvement, for Spanish-speakers like Angie especially but also for other beneficiaries, is communication of benefits and obligations. "Sources of information about changes to benefits are confusing and fragmented," Torres said, "and it often invokes a lot of fear about what's to come."
Angie, for one, reported getting only limited information in Spanish in the past, along with minimal access to Spanish-speaking providers, while other beneficiaries have been receiving mixed messages in various formats about pending changes - via mail from health programs and plans, as well as media reports.
"Well, all I've heard is on the TV that our Medicare is going to be cut. I heard that it would be cut $400," Wilma, an 85-year-old living alone in an apartment with heart disease, diabetes and arthritis, told the HOME Project.
At the same time, "Medicare is always sending me paperwork," Wilma told the researchers. "I just can't handle it right now and I'm giving it to my son and grandson and see what they decide."
As Wilma's weariness with benefit notices suggests, information overload is going to be a huge challenge for California's demonstration and those in other states.
"The success of Cal MediConnect will largely depend on how well informed consumers are," said UCLA's Kietzman.
The program could "dramatically improve care," but the "rollout of this major transition needs to be handled extremely carefully," especially the initial outreach by managed care plans, she said.
One factor health plans, providers and state regulators need to account for is a new Centers for Medicare & Medicaid Services rule requiring "person-centered care planning" of long-term services and supports for demonstration beneficiaries.
That idea holds the promise of addressing shortcoming in care coordination for dual eligible patients, but the "challenge will be to operationalize this," Kietzman said.
"I would suggest that by listening to consumers, that's a very good starting point. We also need to do a better job informing them on their benefits, their choices and their rights."