Orange County has recently joined a handful of other counties statewide a demonstration project designed to enhance care and integrate coordination for residents who are eligible for both Medicare and Medi-Cal, California's Medicaid program.
Dubbed the MediConnect duals demonstration project, it was launched with eight target California counties in 2014 with the goal of eventually expanding Cal MediConnect to all the roughly one million dual-eligibles in the state.
Orange County encountered a few obstacles and is now the last one to launch its program. All duals in Orange County will be enrolled in the project automatically, unless they opt out of it -- a system known as passive enrollment.
The state Department of Health Care Services announced a different kind of delay for part of the project in Orange County -- a plan to offer extended outreach to some of the most fragile duals. Those living in long-term care facilities will get an extra three months before passive enrollment begins.
The shift in long-term care facility residents' enrollment initially caused some consternation in the senior advocacy community, but state officials and health insurers said they just want to take more time to reach out to residents of those facilities, to make sure those frail and elderly patients understand the benefits of Cal MediConnect.
"I wouldn't call it a delay," said Michael Schrader, CEO of CalOptima, the sole Medi-Cal managed care insurer in the Orange County duals project. "It's a strategy that comes from lessons learned in other counties. ... It's a strategic decision to help minimize the opt-out rate, which has been especially high at long-term care facilities."
Concerns and Assurance
Orange County is a particular concern for senior advocates for two big reasons, said Amber Cutler, staff attorney in the Los Angeles office of the National Senior Citizens Law Center, a not-for-profit advocacy group.
"First, there are a ton of duals in Orange County, second-highest in the state," behind Los Angeles County, Cutler said. It has about 57,000 duals, roughly 13 percent of the overall 430,000 duals in seven counties eligible for participation in Cal MediConnect.
And second, Cutler said, "the political past in Orange County provides a different feeling," she said. "That does affect the relationship-building in the community."
Cutler was referring to a 2014 CMS audit that resulted in a temporary halt to participation in the duals program by CalOptima, the only participating insurer in Orange County.
CMS sanctioned CalOptima in January 2014, citing "multiple, serious violations" in CalOptima's handling of seniors and the disabled. It said the insurer denied required prescription coverage, failed to process provider payments in a timely manner and failed to pay for covered emergency services. The CMS audit said those problems were "widespread and systemic."
DHCS officials put off CalOptima's participation for a year, giving the plan till January 2015 to resolve the issues raised in the audit. In November 2014, DHCS extended that timeline to give the plan more time, and said it could not launch passive enrollment efforts in Orange County till August 2015.
"Especially since CalOptima has had issues with Medicare in the past," Cutler said, "we want to keep an eye on it."
"The primary issue then was, with CalOptima's delegated model, we were working with the IPAs (Independent Physician Organizations) and delegating administrative functions to the IPAs," CalOptima CEO Schrader said. "There was very little oversight of the IPAs, and we built in that oversight, so now we're a completely different organization in terms of oversight of our delegated provider partners."
In that way, Schrader said, the care provided to seniors and the disabled has improved considerably. "I think, based on the auditing and oversight, we have a better system," he said. "It wasn't something I'd want to do again, but a lot of good came out of it."
CalOptima sent out notices to beneficiaries in May of its intention to launch passive enrollment beginning this week.
State officials said, outside of a small subset of duals in Orange County, the passive enrollment schedule remains in effect for almost all of the duals in the county.
"The modifications ... affect only a small fraction of the roughly 57,000 dual-eligible beneficiaries in Orange County who qualify for coverage under Cal MediConnect," Adam Weintraub, information officer at DHCS, said in an email response to questions.
According to CalOptima officials, there are about 2,000 dual-eligible beneficiaries living in roughly 60 skilled nursing facilities in Orange County. That's less than 4 percent of the total duals population. The idea is to allow CalOptima to enroll duals on a facility-by-facility basis for those in long-term care.
"The idea behind the modification is to allow for clear and complete communication with these beneficiaries in long-term care," Weintraub said, because they tend to have the most complex medical needs.
"The modified timeline gives CalOptima the opportunity to concentrate educational outreach efforts for long-term care residents, have individual discussions with these patients and their families and to work with facility staff on smooth transitions and continuity of care," Weintraub said.
"All of these targeted efforts will result in closer coordination and more face-to-face interactions between CalOptima staff and care coordinators, beneficiaries, their caregivers and facility staff," he said.
Opt-Out Rates and Lessons Learned
One of the state's big concerns has been the high opt-out rate in Cal MediConnect, particularly in Los Angeles County. According to Cutler, beneficiaries in long-term care facilities were particularly problematic, and she said one lesson learned for the state in Los Angeles County was the importance of moving slowly and clearly with that particular population.
"The high opt-out rates in nursing facilities in other counties, that is a huge factor," Cutler said. "They saw that and thought they could respond to it."
Schrader said that's the main goal of the extended outreach, to provide more information to a population that historically has opted out of Cal MediConnect coverage.
"We're responding to that go-slow request, to reach out to people and explain it to people," Schrader said. CalOptima plans to have family events at the skilled nursing facilities, to make sure not only beneficiaries but also their families understand the ins and outs of the new plan of care.
"This gives us an opportunity to go in-person to those facilities and meet in-person with the families," Schrader said, "and then they can decide if it's right for them."
Cutler said one of the biggest lessons learned from other counties has been that greater communication and outreach is needed to get this vulnerable population to trust the transition to Cal MediConnect.
That's actually a statement about the efficacy of passive enrollment itself, she said.
"Passive enrollment as a process really is the biggest lesson learned," Cutler said. "It just doesn't work well for consumers. For this population in particular … the level of communication needed to inform beneficiaries is really high."
Cutler said the state was hoping to quietly and passively enroll most of the duals into Cal MediConnect and has now launched some of the intense-outreach measures advocates have long pushed to adopt.
"It feels like a flip of the switch now, doesn't it?" Cutler said. "Now they're ... trying to take that intense marketing and high-consumer engagement approach."
Weintraub said the Orange County implementation may benefit from any missteps made in other counties. That includes Los Angeles County, but he said making direct comparisons between L.A. and Orange counties is difficult.
"Los Angeles County, for example, has roughly five times more dual-eligible beneficiaries eligible for Cal MediConnect than Orange County," Weintraub said. "Orange County … [has] a sole Medi-Cal managed care plan -- CalOptima -- while the LA County system has five Cal MediConnect plans."
The biggest difference, though, is that most of the eligible duals in Los Angeles County were in a fee-for-service model.
"But in Orange County the CalOptima system offers a long-term care benefit and already covers care for many of these dual-eligible beneficiaries," Weintraub said. "Through these established relationships, CalOptima has an understanding of the communication and transition needs of this population."
Schrader said, for such a frail population, any changes in care can be scary.
"We've found the biggest barrier to enrollment is people saying, 'Well, what I have works. It's not great, but I know it works,'" Schrader said. "But this is a better way to take care of prospective members, a more patient-centered way of doing things."
David Gorn is a writer for California Healthline.