Bernard J. Wolfson, California Healthline
Teresa Grant, a resident of Culver City, California, has been suffering from debilitating pain for the past year due to a mysterious bulge protruding from the lower chest.
She takes several pain relievers every day. The cause of her agony remains undiagnosed because, despite her persistent efforts, she was unable to get a referral to the right doctor. The 63-year-old Grant participates in Medi-Cal, the California version of Medicaid, a program for low-income people. She is a member of LA Care, one of two Medi-Cal health plans in Los Angeles County and the largest in the state with 2.4 million members.
LA Care and many of the other 24 Medi-Cal managed care plans in the state delegate responsibility for their patients to independent physician associations and, in many cases, other health plans. Plans are also sub-contracted to IPAs, physician networks, which in turn often hire third-party management firms to handle medical approvals and requirements.
This multi-tiered delegated care works in many settings and is common with Medi-Cal managed care, which reaches over 80% of the 14 million enrolled in the program. But advocates, government regulators, and even some health plan leaders agree that this is confusing and disincentive for many Medi-Cal patients, who tend to be poor and minority, often face language barriers and have high the level of chronic diseases.
“You are in Medi-Cal, your last 10 bucks go on the bus, and when you need something, you don’t know who to ask,” said Alex Briscoe, head of the California Children’s Trust and former director of Alameda. County health care agency. “Complexity is like salt in the wounds of people trying to navigate the healthcare system.”
Moreover, health plans often have weak oversight of subcontractors, allowing some to escape the penalty of poor care or unjustified denials. The state has pledged to tighten rules for Medi-Cal plans and providers in new managed care contracts that will take effect in 2024.
Although Medi-Cal spending is projected to hit a record $ 124 billion this fiscal year, healthcare providers often complain that their payments are inadequate, and critics say each level of administration reduces the amount of dollars available to healthcare.
Worst of all, such a confusing system can physically harm students. Grant, who describes herself as a person of color, spends most of her time locked up at home and has to resort to additional pain relievers just to shop or do laundry. “I was muscular. I have always used my body. Now I don’t even recognize myself, ”she said.
While LA Care is ultimately responsible for the Grant, it outsource its services to a network of physicians called the Prospect Medical Group. Prospect, in turn, enters into an agreement with the medical management company MedPoint Management.
Grant said she moved from Prospect to MedPoint, LA Care and eventually the Department of Managed Healthcare, one of two state health insurance regulators, seeking approval to see a thoracic surgeon for her chest. But the doctors she was referred to were either of the wrong type, or were already treating her unsuccessfully, or they were repeatedly sued for abuse of office. Some, she said, no longer practice or have moved out of the state.
LA Care said in a statement that it “takes all member concerns that are brought to the attention of the health plan seriously” and “has a hard time knowing when a Los Angeles County resident is not getting the care they need.”
LA Care, which relies on delegation more than any other Medi-Cal plan in the state, has about 58 subcontractors. This group includes three health plans – Kaiser Permanente, Anthem Blue Cross, and Blue Shield of California – and about 55 doctor networks. Community clinics and the county health system are also part of the LA Care network.
CalOptima, which operates Medi-Cal for 860,000 Orange County beneficiaries, is subcontracting with Kaiser Permanente and 11 physician associations, COO Junkyung Kim said.
The Alameda Alliance for Health, one of two Medi-Cal health plans in Alameda County, delegates overall responsibility for about 43,000 of the 300,000 Kaiser Permanente members, said Scott Coffin, its CEO. He also subcontracts varying degrees of responsibility to a chain of community clinics, a pediatric medical team, and the county’s public health system.
Typically, insurance plans pay their subcontractors a flat monthly fee per member. The plans take a percentage of the money they receive from the government to cover the supervision of their subcontractors, and are usually financially independent of caring for these patients.
“This is a solid portion of our bottom line and gives some stability to our finances,” said John Baakes, CEO of LA Care.
Health plan executives say subcontracting gives patients more choice.
In Los Angeles County, for example, the state contracts with two health plans: LA Care and Health Net. Because LA Care subcontracts three other health plans and Health Net subcontracts one, Molina Healthcare, Medi-Cal members can choose from six plans.
Skeptics say the idea of wider choice is illusory, because whichever plan patients choose, they end up in a network of doctors and are usually limited to their providers.
“They act like mini-plans within a plan, and their networks are very narrow,” said Abigail Kursoll, senior associate with the National Health Law Program in Los Angeles.
Baakes said Medi-Cal members can change providers every month if they choose. But some may not know they have this right, and others, like Grant, may not want to change. “I don’t want to join another IPA because I’ll lose my PCP and I’ll have to start from scratch,” she said.
“Changing providers every month is not conducive to good health,” said William Barcellona, executive vice president of government affairs for America’s Physician Groups, which represents IPA and medical groups.
When people first go to managed care, he said, they need to be screened for chronic illness and mental health, and then given the help they need. “You can’t do that if someone can just navigate the system every 30 days.”
When properly delegated, it can be a more effective way of delivering assistance, especially in large, densely populated counties with diverse communities.
“It’s like a contractor in a house. Does it make sense for the contractor to do the wiring, plumbing and drywall? Asked Jennifer Kent, who ran the Department of Health, which administers Medi-Cal, from 2015 to 2019. “He could, and if he’s good at it, great. But he’s probably not as effective as overseeing a drywall specialist and plumber and keeping an eye on quality. “
But that becomes a problem when health plans are not controlled by medical groups, Kent said. And that’s a big problem for Medi-Cal, advocates, patients, and government health officials agree.
The new Medi-Cal contracts will “significantly strengthen and clarify the requirements and expectations” for managed care plans for supervision and compliance by subcontractors, said Anthony Kava, spokesman for the Department of Health.
The contracts will specify what requirements should be included in subcontractor agreements and outline certain functions that managed care plans cannot delegate, Kava said. The contracts will also require plans to report timely access and quality of service for each of their subcontractors.
Plans currently only provide data in the aggregate, which hides large performance differences and allows low-quality performers to avoid detection. This means that government-published health plan quality indicators do not always reflect patients’ real-life experiences. Health plans find it difficult to obtain patient visit reports from their physician groups, who in turn often have difficulty getting reports from physicians in their networks.
To be sure, some plans have already attempted to measure the performance of their subcontractors.
The Alameda Alliance has set up a committee to oversee its subcontractors, Coffin said. He oversees the annual audits and publishes “dashboards” to track the work of subcontractors.
Baakes said that when he first took over LA Care in 2015, medical teams offered inconsistent quality services. He has implemented a report card for all subcontractors and since then the laggards have improved their game, he said.
But Baakes is not a big fan of the forked delegation system he inherited. Administrative levels do this at a cost, and each one “adds the ability for someone to throw a ball,” he said.
Grant and other members who feel that Medi-Cal is serving them poorly will certainly agree.
Last week, Grant finally reached out to a UCLA surgeon who she thought could help her. A surgeon specializing in cardiovascular diseases did not find an answer to her chest problem, but found a stain on her lung. Once again, Grant was left on her own and had to make several phone calls to schedule a CT scan of the growth.
She praised her attending physician and his assistant as “caring and good people” who tried to help her. But she feels betrayed by the system.
“It’s like they’re deliberately confusing you to gain the upper hand,” she said. “This is how I see it. How could I not? “