CalOptima to Take Part in State’s ‘Dual-Eligible’ Pilot Program

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Orange County is among four California counties that are part of a state pilot program aimed at managing health care “dual eligible” adults, people who qualify for both Medi-Cal and Medicare services.

The goals are to save money by allowing these adults — about 75,000 in Orange County — to remain in their homes rather than be sent to more expensive nursing homes and to create a better system overall for elderly and disabled adults who meet the criteria for both government-run programs.

A key issue is getting a large number of qualified doctors and other medical professionals to participate so patients need not switch physicians and other providers when they join the program.

Orange County will participate through CalOptima, its $1.4-billion health plan for poor residents. Los Angeles, San Diego and San Mateo counties were also selected. Ten counties applied for the three-year pilot program. The project still requires approval by the federal Centers for Medicare & Medicaid Services.

Richard Chambers, former CalOptima CEO whose resignation became effective last week, told the CalOptima board that Orange County faced stiff competition for the pilot program.

He said one advantage CalOptima had was that its staff spoke during the application interviews with direct knowledge of patient needs and how care is managed. Some other counties relied on applications written by consultants and others who wouldn’t be directly managing the program.

Chambers said the dual pilot program is an opportunity for CalOptima “to be on the cutting edge” of helping people remain in their homes rather than transferring to nursing homes by helping coordinate their health care.

The state expects each of the four counties to have its dual pilot programs in operation by Jan. 1.

“The task is great, but [at CalOptima] everyone’s up to it,” said Chambers. “We’re going to put 1,000 percent behind it.”

Nationally, individuals who are dual-eligible constitute 18 percent of Medicare enrollment but account for 46 percent of the cost, according to 2005 figures, the most recent available. Total cost nationally for coverage of dual-eligible individuals was $287.3 billion. About 1.1 million adults are eligible for the program statewide, including 75,000 in Orange County.

The Los Angeles Times reported last week that patients’ rights organizations are worried that the program will disrupt ongoing patient care and that not enough providers will enroll, forcing patients to switch doctors.

— TRACY WOOD

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