A key quality-of-care rating for a CalOptima health plan that covers 13,000 low-income, elderly Orange County residents dropped slightly this month, but officials said it isn’t a sign of trouble.
But others familiar with the program, known as OneCare, said the drop should be closely monitored at an agency that has experienced more than a year of management turmoil.
The federal Centers for Medicare and Medicaid Services rates various programs it funds to encourage high-quality care and reduce the need for expensive emergency room visits.
Programs are awarded from one to five stars, based on rankings in a variety of categories, such as how well the medical groups in the OneCare plan review the medications taken by elderly patients under their care and manage conditions like pain and diabetes.
Higher rankings bring financial incentives that help the federally financed health plans offset losses in other areas or help build reserves.
CalOptima saw its 2013 ranking for One Care drop from a 4 to 3.5.
CalOptima spokeswoman Kellie Todd said the change was caused by other plans improving their programs. “We didn’t do any worse, but the other plans did a little better,” she said. “We’re pretty much where we usually are.”
At least 18 key executives, including the CEO, chief financial officer and chief operating officer, left CalOptima in the past 17 months, most following dramatic changes initiated last fall by Supervisor Janet Nguyen. Many remaining executives are handling two or three jobs that, like OneCare, once had an executive solely in charge of monitoring its effectiveness.
Federal officials said they don’t comment on individual programs. But others familiar with CalOptima said the OneCare program used to have one executive whose sole job was to work with the medical groups that provided the care to patients and make sure they were performing well. That executive left in July 2011, and since then the work has been handled by staff members who also have other management responsibilities.
Michael Schrader, who has most recently served as chief operating officer of the Boston Medical Center HealthNet Plan, takes over as CalOptima’s CEO at the end of this month.
A better sense of how serious the drop in star rating is will come in the spring of 2013 when the next Healthcare Effectiveness Data and Information Set ratings are released. Those scores measure a wide range of health care standards, like blood pressure, diabetes and asthma care. Health plans with high ratings promote them.
Earlier this year, CalOptima announced it completed a stiff, three-year evaluation and now is accredited by the National Committee for Quality Assurance, which issues the healthcare effectiveness ratings.
Its score of 87.01 placed it at the top of the list among California Medi-Cal plans and in the top six Medicaid plans in the nation, according to the CalOptima news release.
With a yearly budget of $1.4 billion, CalOptima serves about 424,000 Orange County residents.
Its high statewide rankings helped qualify it as one of four California counties enrolled in a pilot program to serve “dual eligible” residents, those who are covered by both Medi-Cal and Medicare. There are about 75,000 “duals” in Orange County, and medical providers are competing for permission to care for them.
— TRACY WOOD
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