State over­sight of Medi-Cal plans is faulted

Man­aged-care plans aren’t be­ing made to pro­vide guar­an­teed ac­cess, an au­dit finds.

Los Angeles Times - - CALIFORNIA - By Soumya Kar­la­mangla

Since sign­ing up for Medi-Cal more than a year ago, Kevin Hill hasn’t been able to find a doc­tor. He said he called at least 15 physi­cians near his home in Long Beach who were listed in his health plan’s provider di­rec­tory.

But ei­ther the phone num­bers didn’t work or the doc­tors weren’t ac­cept­ing new pa­tients, he said. He’s given up.

“Now I just go to an emer­gency cen­ter to pay cash even though I can barely af­ford it,” the 58-year-old said.

Prompted by com­plaints like Hill’s, the Cal­i­for­nia state au­di­tor last year be­gan eval­u­at­ing how the state over­sees much of its health pro­gram for low-in­come res­i­dents. The re­sult­ing au­dit re­leased Tues­day found that provider di­rec­to­ries were rid­dled with er­rors and that the state Depart­ment of Health Care Ser­vices hadn’t prop­erly reg­u­lated plans to guar­an­tee pa­tients ad­e­quate ac­cess to doc­tors.

“The au­dit con­firmed our long-stand­ing con­cerns about ac­cess for Medi-Cal pa­tients,” said An­thony Wright, ex­ec­u­tive di­rec­tor of the ad­vo­cacy group Health Ac­cess Cal­i­for­nia. “The find­ings of the au­dit cry out for more over­sight.”

Since el­i­gi­bil­ity was ex­panded un­der the Af­ford­able Care Act last year, Medi-Cal en­roll­ment has bal­looned, with more than 3.5 mil­lion peo­ple sign­ing up for the first time. Nearly one in three Cal­i­for­ni­ans — a to­tal of 12.3 mil­lion peo­ple — now re­ceive cov­er­age through the pro­gram.

Re­quested by state Sen. Ri­cardo Lara (D-Bell Gar­dens), the au­dit ex­am­ined Medi-Cal man­aged-care

pro­grams, which are health plans that con­tract with the state to co­or­di­nate and pro­vide care, and cover 78% of Medi-Cal pa­tients.

Au­di­tors an­a­lyzed the provider di­rec­to­ries of three plans — An­them Blue Cross in Fresno County, Part­ner­ship Health­Plan of Cal­i­for­nia in Solano County and Health Net in Los An­ge­les County — and found that they con­tained in­ac­cu­rate in­for­ma­tion for 3% to 23% of providers.

The state is re­quired to cer­tify that health plan net­works of­fer enough doc­tors, and that pa­tients don’t have to drive too far to get care. But the au­dit found the state couldn’t be cer­tain the plans were meet­ing pa­tients’ needs, be­cause the Depart­ment of Healthcare Ser­vices wasn’t ver­i­fy­ing the data that plans sub­mit­ted to the state.

For in­stance, although the depart­ment had not found “any in­ac­cu­ra­cies in the three provider di­rec­to­ries,” au­di­tors said they dis­cov­ered wrong tele­phone num­bers and list­ings for doc­tors who were no longer in the pro­grams.

Depart­ment di­rec­tor Jen­nifer Kent said Tues­day that her staff works dili­gently to en­sure plans are meet­ing their re­quire­ments, and that the au­dit only looked at a por­tion of the agency’s mon­i­tor­ing ef­forts.

“We ap­pre­ci­ate to­day’s re­port from the Cal­i­for­nia state au­di­tor that un­der­scores the need for con­tin­u­ous im­prove­ment and en­hance­ment of the state’s over­sight of Medi-Cal man­aged care, some of which the Depart­ment of Healthcare Ser­vices was well un­der­way in ad­dress­ing,” she said. The au­dit rec­om­mends that the depart­ment im­prove its process for ver­i­fy­ing plan data and es­tab­lish a clear process for do­ing so by Septem­ber of this year.

“While dis­ap­point­ing, the re­sults of this au­dit are not sur­pris­ing,” said State Sen. Ed Her­nan­dez (D-West Cov­ina).

Her­nan­dez has al­ready in­tro­duced leg­is­la­tion that tack­les some of the prob- lems con­firmed by the au­dit. SB 964, signed into law by Gov. Jerry Brown last year, re­quires the state to make sure Medi-Cal man­aged­care plans of­fer suf­fi­cient doc­tor net­works. And SB 137, which has been passed by the state Se­nate but not the Assem­bly, would re­quire plans to post provider di­rec­to­ries online and up­date them weekly.

Of­fi­cials say many peo­ple have ben­e­fited from be­ing able to sign up for Medi-Cal, which is free for pa­tients.

Glendale res­i­dent Lori Mar­garet, who has en­dometrio­sis, signed up at the be­gin­ning of 2014. She had been un­able to get health in­sur­ance through work.

Last year, the 45-year-old be­gan hem­or­rhag­ing and had to have a hys­terec­tomy, which she couldn’t have paid for on her own.

“Ev­ery­thing was cov­ered,” she said. “I’m so grate­ful ev­ery day be­cause I had that.”

With thou­sands of peo­ple added to Medi-Cal, the Depart­ment of Healthcare Ser­vices’ om­buds­man, which re­solves com­plaints from ben­e­fi­cia­ries, has been over­whelmed with calls. Ac­cord­ing to depart­ment data ob­tained by The Times, the av­er­age monthly num­ber of calls and emails to the of­fice jumped from 14,000 in 2013 to 24,000 in 2014 to 32,000 in the first five months of this year.

That vol­ume has been more than the of­fice’s tele- phone sys­tem can han­dle, the au­dit found. Be­tween 7,000 and 45,000 calls were re­jected each month be­tween Fe­bru­ary 2014 and Jan­uary 2015, and in­ad­e­quate staffing has meant that only be­tween 30% and 50% of the calls the tele­phone sys­tem ac­cepted were ac­tu­ally an­swered — mean­ing an ad­di­tional 12,500 unan­swered calls each month dur­ing that time pe­riod.

Depart­ment of­fi­cials say they have or­dered a new phone sys­tem.

Many ad­vo­cates said the ac­cess is­sues re­ported in the au­dit are partly due to low pay­ment rates for Medi-Cal doc­tors. Those rates, which were low­ered by state law­mak­ers dur­ing the re­ces­sion, dis­cour­age doc­tors from tak­ing on more pa­tients, they say. The rates only ap­ply to the roughly one-quar­ter of pa­tients who are not en­rolled in man­aged­care plans, and for whom the state is billed for each doc­tor visit and med­i­cal pro­ce­dure in­di­vid­u­ally.

“Medi-Cal needs to be fully funded or we will con- tinue to have a two-tiered healthcare sys­tem in our state: a dys­func­tional, in­ad­e­quate sys­tem for Medi-Cal pa­tients ... and a much higher-func­tion­ing sys­tem for peo­ple with pri­vate health in­sur­ance,” said Dave Re­gan, pres­i­dent of Ser­vice Em­ploy­ees In­ter­na­tional Union-United Healthcare Work­ers West, in a state­ment.

The rates have been a re­cur­ring is­sue dur­ing spend­ing ne­go­ti­a­tions in the Capi­tol. A fi­nal bud­get deal an­nounced on Tues­day in­cludes some money to re­store cuts in den­tal care, but not a broader in­crease in rates for all doc­tors.

The gover­nor, who wants to re­vise and ex­tend a tax on man­aged-care plans, said he would call a spe­cial leg­isla­tive ses­sion this year to ad­dress is­sues in­volv­ing Med­i­Cal fund­ing.

‘Medi-Cal needs to be fully funded or we will con­tinue to have … a dys­func­tional, in­ad­e­quate sys­tem for Medi-Cal pa­tients.’

— Dave Re­gan,

SEIU-United Healthcare Work­ers West

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