By Tom Kisken
Ventura County Star
SACRAMENTO, Calif. — Nursing homes, ambulance companies, doctors, hospitals, home health care workers and about 100,000 consumers may see their world tilt on Friday when the Medi-Cal insurance system for low-income people transforms into a locally run HMO.
In the works since a 2005 state mandate, the change means a state-conducted system becomes a locally run network with an annual budget of about $300 million. It means as many as about 50,000 Medi-Cal members who haven’t chosen their doctors will be assigned to primary care physicians who will coordinate their care.
Many health care providers worry the change could mean less money and more problems in getting it. But leaders of the transformation say pairing each patient with a clinic or doctor’s office that serves as a medical home means people will be guided to the care they need rather than struggling to find doctors on their own or delaying care until they need an emergency room. State officials said the managed care system will eventually cost as much as 10 percent less than the current system. ‘Ultimately, it will improve access to care and outcomes of care and it will reduce the taxpayers’ burden,’ said Earl Greenia, CEO of the new system, the Gold Coast Health Plan.
The switch will be thrown Friday. People who qualify for Medi-Cal for doctors appointments, prescription drugs, home health care and other services will be covered by the new plan. Their complaints and concerns will be answered by a 42-person call center in Lexington, Ky.
As of last Friday, about 15,000 people on Medi-Cal had sent in their paperwork choosing a primary care doctor. As many as 30,000 people covered by both Medi-Cal and the federal Medicare program don’t have to submit a new choice.
That means about 55,000 people need to make the selection or they will be assigned to a physician.
“Fifty-five thousand is a big number,” said Dr. Robert Gonzalez, director of the Ventura County Health Care Agency, noting people will still be able to choose doctors after Friday. “I believe there’s going to be a lot of settling out over the first two or three months of the program.”
Some observers predict varying levels of chaos with people showing up at the wrong doctor’s office or being told their specialists are no longer covered by the plan. They worry low reimbursement rates mean relatively few patients will see private doctors, meaning more pressure on facilities designed to serve low-income patients.
“When the dust settles it will actually be beneficial for the patients mainly because it will force them to have coordinated care,” saidDr. WilliamGoldie, a pediatric neurologist at Ventura County Medical Center in Ventura. “Getting to that level is going to be painful and chaotic.” Gold Coast Health Plan leaders say they expect challenges, not chaos. They say a two-month grace period should mean patients won’t be turned away even if they show up at the wrong doctor. Providers say the same thing. “We’ll take care of patients and hope that things get sorted out equitably after the fact,” said Mike Lurie, vice president of planning and managed care at Community Memorial Health System in Ventura. With a few exceptions like group homes for the developmentally disabled, the new plan affects every aspect of health care received by people in Medi-Cal. That means it impacts ambulance companies, hospice care, nursing homes, home health care, outpatient centers and X-ray imaging sites.
“I’m totally confused at this point. Oh, man,” said Dave Merkley, nursing home administrator at Glenwood Care Center in Oxnard, a few hours after a Thursday conference call designed to end his confusion. He worries a new system could mean delays in the approvals needed for a nursing home to accept new patients. Gold Coast administrators say they hope to deliver the authorizations within one day.
Others expressed little angst.
“I don’t think it’s really going to change anything,” said Wynne Schumacher, director of business development at LifeLine Medical Transport ambulance company in Ventura. “The only thing that will change is where we send our claims.”
Much anxiety is focused on money. Merkley worries about formulas that determine cost-sharing between Medicare and Medi-Cal. Shelley Chilton, administrator of TLC Home Hospice in Moorpark, worries it might be more difficult to get reimbursed through the new plan.
Doctors stress over the $8.38 a month rate they’ll be paid for each Medi-Cal member whether they see the patient or not. Independent pharmacists worry about a rate that John Skovmand, owner of Seeber’sUnitedDrug inSanta Paula, said could drop his Medi-Cal reimbursement 30 percent or more.
“Scary low,” he said of the new rate. “I just hope we’ll beable toprovide the services to these patients that they’ve come to expect.”
Gold Coast leaders have challenged such projections in the past, saying the total pharmacy compensation rate is about 7 percent less in the new system compared to state-run Medi- Cal. Greenia said he understands the importance of prompt payments, contending the local system will be more accessible to providers who in the past took their complaints to Sacramento.
But he also acknowledged there’s a reason for the concerns about money. Medi-Cal is designed as a last resort safety net program for people who have no other way to get insurance.
“It’s not intended to make providers whole as far as covering full costs,” he said.
Some people with families covered by Medi-Cal say they don’t know enough about the program to know if they should worry. Sally Hand of Ojai responds to questions by reciting detailed information about the new plan and the advantages of it being run locally.
“I think it’s going to get better,” said Hand, who is applying for Medi-Cal, which covers her 5-yearold daughter. “I think it will be easier.”
State leaders say the same things as Gold Coast Health Plan leaders: The changes will mean access to coordinated care for people at a financial savings for taxpayers.
“I know that’s what they say and that’s the intent,” said Skovmand, the pharmacist. “We’ll just have to see what happens in the real world when it shakes out.”
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