photo: Dr. Esiquio Casillas is the regional medical director for Senior Services at AltaMed, a network of community clinics in Southern California.
LOS ANGELES—A new California health care program for low-income seniors and people with disabilities promises for the first time to coordinate not only patients’ hospital and physician coverage, but also factors like healthy nutrition, access to transportation and social-support systems.
The World Health Organization calls these “social determinants of health” that are essential to patients’ well being, said Dr. Esiquio Casillas, regional medical director for Senior Services at AltaMed, a network of community clinics in Southern California.
The new program, called Cal MediConnect, is a pilot project under the federal Affordable Care Act in eight California counties. In the first three years it is targeting 450,000 people—almost half in Los Angeles County.
It started enrolling eligible people April 1, on a voluntary basis and will fully take effect in Los Angeles on July 1. That’s when those who haven’t signed up will be assigned to one of five project health plans.
Medicare Not Enough
Speaking recently at a forum for ethnic media and community stakeholders, organized by New America Media, Casillas described stressful and wasteful situations in the current system that he and other health care providers hope will end with the new, coordinated-care approach. Dozens of older adults also participated in the event, held at the St. Barnabas Senior Center in collaboration with the Los Angeles Aging Advocacy Coalition.
For example, he said, “With just the Medicare benefit, if you’re working with a patient with diabetes, you can’t really manage them appropriately unless you can address their nutrition – unless they actually have a working refrigerator, unless they have some kind of access to healthy meals. Same thing with high blood pressure and other types of heart diseases.”
Also, he said, the new Cal MediConnect program should help patients with Alzheimer’s disease or related dementias coordinate their medical care with caregiver support services at home. Many have received state In-Home Supportive Services (IHSS) benefits, he said, but if those services aren’t coordinated with a provider [and] the medical system, they won’t be part of a truly effective care plan.
Cal MediConnect will provide each patient with a care coordinator and add previously uncovered vision care and non-emergency transportation, such as for doctors’ visits. It will combine federal Medicare benefits with health services under MediCal (California’s name for state-administered Medicaid for low-income people.)
Patients will also have access to a care team. Not only their doctor, but also a nurse, social worker, nutritionist, physical and occupational therapists, transportation coordinator and other specialists will establish each person’s health plan.
Participating insurers must also offer an adequate provider network with enough specialists, primary care physicians, language interpretation and others.
A major change through Cal MediConnect is that MediCal will now manage three programs considered national innovations 30 years ago, but which were not coordinated into seamless patient care. They include the state’s IHSS home care program, adult day health and case management.
California is one of about 20 states participating in the three-year demonstration project through the Affordable Care Act aimed at improving care while reducing unnecessary cost.
Casillas noted that Cal MediConnect is partly based on PACE, or the Programs for All-Inclusive Care for the Elderly. Created 40 years ago in San Francisco’s Chinese community, PACE combines Medicare and Medicaid funding and allows health providers to give patients appropriate care with fewer bureaucratic barriers. Casillas directs the PACE program at AltaMed.
Blue Envelopes Offer Three Options
The hope with Cal MediConnect, he said, “is an improvement over the status quo for patients and providers’ offices.”
Those being brought into the new system are receiving blue envelopes from the state Department of Health Services explaining three options. Eligible beneficiaries can enroll in a Cal MediConnect plan blending both their Medicare and MediCal coverage; they can sign up for only a MediCal managed care plan while keeping their current Medicare coverage; or in Los Angeles they can join a PACE plan.
Addressing the community forum audience from his wheelchair, Jorge Chuc, a Latino community peer mentor with Personal Assistance Services Council-L.A., said at first he was worried that with Cal MediConnect he might lost his doctor, a widespread concern in the community, and one Casillas acknowledges.
“A huge challenge the system is going to face,” he said, “is that doctors in the community who have not previously participated in and are not contracted with a [Cal MediConnect] plan are still the key link to the patients and still provide a lot of influence and education.”
Many doctors, however, remain unaware that plans can include them for up to a year without their having to join the managed care network. “Plans are working hard to engage those providers in their networks, because they are a crucial link [to patient care],” Casillas went on.
Most important, Chuc declared, “Open the blue envelope, read it, choose the best plan.”
Cal MediConnect includes five plans available in L.A. County – Care First, Care More, HealthNet, LA Care and Molina.
Patient’s Confusion—and Rights
Amber Cutler, staff attorney for the National Senior Citizens Law Center, emphasized that even if dual Medicare-MediCal beneficiaries wait until after July 1 and find the state has enrolled them in a new plan, “You have the right to disenroll from Cal MediConnect or change plans at any time for any reason.”
She added, “Keep in mind, though, that you’d still have to enroll in a MediCal Managed care plan.” That’s because the state is moving all MediCal recipients out of customary fee-for-service insurance and into managed care plans. The federal Medicare, however, always allows patients to switch back to fee-for-service coverage.
Aileen Harper, executive director of L.A.’s Center for Health Care Rights told the forum audience, “Many consumers find the Cal MediConnect program confusing.”
Harper’s agency includes the county’s Health Insurance Counseling and Advocacy Program (HICAP), charged with helping the public at no cost – in all languages – to understand their health care choices. Notices from the state, including in the blue Cal MediConnect envelopes, list HICAP’s toll-free 800 number.
She explained that HICAP is responsible for helping people navigate their Cal MediConnect options by enabling them to understand notices from the state and fill out enrollment forms. HICAP counselors will also help beneficiaries find out if their doctors are part of the five participating plan networks.
Also listed on notices to affected Los Angeles County residents is the toll-free number for the Health Consumer Center at Neighborhood Legal Services of L.A.
Supervising Attorney Stephanie Lee said the state designated the program as the independent Cal MediConnect ombudsman tasked with helping consumers with problems, such as filing appeals and complaints or obtaining referrals to other organizations they may need.
One recent caller, for instance, was a Korean-speaking nursing home patient, age 81, who was concerned she may have to move to another home. Lee said the senior could neither reach her physician nor get answers from the facility because a Korean speaker was not always available.
“We were able to educate her and see what plans her nursing home and doctor worked with,” Lee said.
Serving Vulnerable Populations
“The overarching issue,” she stressed, “is that this program involves vulnerable populations, who may not be able to understand what is happening or be able to make any decisions.”
At the St. Barnabas forum, several participating seniors, such as Anacleto Mendoza of the Filipino American Service Group Inc., and, speaking through an interpreter, Kang Nam Lee, a volunteer at the Korean Resource Center, raised a range of concerns as Cal MediConnect goes into effect. Their worries ranged from the possible continuation of past, disorganized care to losing a doctor of 20 years who speaks the patient’s language.
Overall, Casillas explained, “The challenge will be in the first few months of the program to make sure the patient is assigned to the right case manager and care team. There may be some barriers to doing that as they initially enroll, but the structure of this program should address those issues.”
Her program’s toll-free phone number is 800-896-3202.
This article is part of New America Media partnership with Harbage Consulting on this California-wide Cal MediConnect media campaign to support the Department of Health Care Services' stakeholder engagement efforts. Additional support for this initiative comes from The SCAN