Patients who are being moved into Medi-Cal managed care plans as part of a major statewide policy shift are facing life-threatening obstacles to getting needed care, according to patient advocates who testified in a legislative oversight hearing.
An attorney, doctor and lobbyist pleaded with lawmakers on Wednesday to slow the pace of a program overhaul that they say has knocked patients off organ transplant waiting lists or upended care that kept chronic diseases under control.
The changes are part of a wide-ranging plan that is meant to improve care and cut costs in the state’s Medi-Cal program, California’s version of Medicaid. In June, the first wave of Medi-Cal patients moved to managed care plans.
The effort is planned to extend to about 1.2 million seniors who are covered by both Medicare and Medi-Cal and projected to save the state a billion dollars within five years.
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The changes are expected to prepare California for continued implementation of health reform in 2014, when an additional 2 million residents are expected to qualify for Medi-Cal under expanded eligibility rules.
Leaders from the state Department of Health Care Services, which runs Medi-Cal, have pledged a seamless transition to managed care coverage. Advocates at the hearing, however, say it has been anything but.
Katie Murphy, supervising attorney with Neighborhood Legal Services of Los Angeles County, said her advocates are trying their best but failing to help patients who are being cut off from their doctors and denied care.
She said one patient was scheduled for surgery for a collapsing eye socket before her health provider was changed. Her request to keep the appointment was denied.
Murphy said another patient who was accustomed to monthly cortisone shots for pain was told to come once every three months or pay for additional care herself.
Advocates sought a temporary exemption from managed care for another patient with schizophrenia and diabetes. Although advocates explained the patient feared meeting a new doctor, they were denied.
“These are a few examples," Murphy said. "We have dozens a week.”
Dr. Patricia Samuelson, a Sacramento physician who testified on behalf of the California Medical Association, offered additional examples from her practice.
Samuelson said one of her patients had symptoms of hepatitis C that were under control. But after the patient was moved into a managed care program, her medications were delayed for weeks. “She may have lost her chance to be cured of this illness,” Samuelson said.
For another patient who needed treatment for a rare form of high blood pressure, Samuelson said she had to produce the results of an old test to prove to a new health plan that the patient qualified for needed care. “I had to get archived records and go through four volumes to keep this man alive,” she said.
In an interview after the hearing, Samuelson said the transition is difficult.
"I'm here on nights and weekends filling out forms," she said. "It's aggravating for me. For (patients), it's life and death."
Michael Arnold, a legislative advocate for the California Dialysis Council, said about 5,000 patients with end-stage renal disease who require dialysis are having a hard time accessing transportation services under new managed care programs. During dialysis treatments, patients with limited kidney function have their blood filtered by a machine.
Arnold said patients who were on lists to get kidney transplants had to start the process again with new health providers. “Such delays could mean that the patient will die prior to receiving the transplant,” he said.
Arnold said social workers who seek patient exemptions from the managed care system – which would allow patients to continue seeing their usual doctors – are not succeeding. “The exemption process does not work,” he said.
From June to December, about 12,800 Medi-Cal beneficiaries requested exemptions that would allow them more time to transition to managed care. Of those, about 15 percent, or 1,900 requests, were approved, agency figures show.
Another 7,500 requests were deemed incomplete and sent back to care providers. About 3,400 requests were denied, said Norman Williams, spokesman for the Department of Health Care Services.
Assemblyman Bill Monning, D-Santa Cruz, who attended the hearing, said he introduced a bill that would strengthen the current managed care exemption process, making it state law that is less subject to interpretation than current regulations.
Toby Douglas, director of the Department of Health Care Services, told members of an Assembly budget subcommittee and the Committee on Aging and Long-Term Care that the health care system is moving to a more coordinated, patient-centered approach.
Under the new rules, health plans and physician groups will get monthly per-patient payments for care. If they succeed in managing chronic diseases without expensive emergency and nursing home care, they will come out ahead financially. The system is an about-face from a fee-for-service system that heaps financial rewards on health care providers who order the most tests, scans and services.
Douglas said his department “can always improve” and is launching seven working groups to tackle challenges with the move to managed care.
He said a poll of about 460 patients recently moved to managed care found that 87 percent reported that their ability to make appointments was the same or better than it had been under the old system. “We’ve been doing a lot to make sure this goes as smoothly as possible,” Douglas said.
As of January, 170,000 Medi-Cal recipients have been moved into managed care plans, Williams said. A total of 380,000 seniors who are not covered by Medicare and people with disabilities are expected to be moved by June.
The Legislative Analyst's Office has cautioned against a plan that would hasten the movement of 1.2 million seniors who qualify for Medicare and Medi-Cal into managed care programs.