Huge Experiment Aims To Save On
Care For Poorest, Sickest Patients: Many Seniors
10, 2012 - Editor’s Note: Too often baby
boomers and senior citizens ignore the Medicaid program, assuming they
will never need that medical assistance for the poorest. It also happens
too often that many who thought that find they do, as medical, housing
and long-term care expenses devour their nest egg. Medicaid becomes the
last resort for survival. It has become a real focus of controversy as
federal and state governments struggle to fund it. This report focuses
on possible solutions for those seniors who qualify for Medicare and
Medicaid – the “dual-eligibles,” they are called - as well a younger
patients who cannot afford care.
Mary Agnes Carey and
Sarah Varney, KHN Staff Writers
This story was produced with
Dec. 10, 2012 - It is usually after
the mail arrives that Della Saavedra comes undone. That's when she sits
in her living room in this struggling Los Angeles suburb (Pico Rivera)
and sorts through the latest round of letters from her health plan, each
rejecting her appeal to stay with her trusted oncologist at City of
Hope, a local cancer center.
For as long as she can remember,
Saavedra, 53, a former cafeteria worker who suffers from bone marrow
cancer, has been insured through Medicaid, the joint federal-state
program for low-income people. For most of that time, she could go to
any doctor willing to take her, but last year, the state revamped the
program and assigned her to a managed care plan with a restricted
network of doctors. Her oncologist is not on its roster.
"I have been sick for years and no
problem," says Saavedra. "Now, it’s a huge problem."
Saavedra is one of a large group of
disabled Medicaid enrollees in California who have been moved out of
traditional fee-for-service health coverage into a managed care plan.
Officials hope to learn if the transition provides this vulnerable
population, which has complex medical needs, better medical care while
saving the government money.
The California experiment, now in
its second year, has national significance. Federal officials have begun
to roll out a similar, but larger effort required by the Affordable Care
Act. That program will move up to 2 million of the nation's sickest and
most expensive patients into managed care. Twenty-five states have
applied to be part of the managed care experiment for so-called
"dual-eligibles," people who qualify for both Medicare and Medicaid. All
dual-eligibles are poor, two-thirds of them are over 65, and many of
them suffer from multiple chronic illnesses like diabetes and heart
Massachusetts and Washington, the
first states to be approved, will start their programs April 1.
Patient advocates around the
country, and some lawmakers in Congress, warn that managed care plans –
some run by for-profit, publicly traded companies – are ill-equipped to
deal with the complex health needs of those who are elderly, mentally
ill or disabled. Advocates are looking closely at the experiences of
patients like Saavedra in California to see what the pitfalls of the
national program may be.
"We have to think about the fact
that people’s lives are at stake," says Kevin Prindiville, an attorney
with the National Senior Citizens Law Center.
Sick, Frail And Expensive
Federal and state governments spend
nearly $300 billion each year on the medical and home care needs of
patients who are enrolled in both Medicaid and Medicare. They account
for 31 percent of Medicare’s spending and 39 percent of Medicaid’s
spending, according to the Centers for Medicare and Medicaid Services.
include some of the most chronically ill and complex enrollees in both
programs," says Melanie Bella, who is overseeing the experiment as
director of the Medicare-Medicaid Coordination Office. "The current
system presents many navigational challenges due to complex and often
is trying to save money by moving thousands of its patients into managed
care health plans. For Juan Cameros, that meant he could no longer see
the surgeon who had been treating him. Watch the video.
The goal is to improve the care of
these fragile patients by coordinating it better. The system could save
money by eliminating needless tests, duplicative office visits and too
Those are sound principles, but the
size of the experiment worries many. "They are too big to fail," says
Robert Berenson, a former vice chairman of the Medicare Payment Advisory
Attorney Vanessa Cajina concurs.
She has represented several patients in the California Medicaid managed
care experiment in her work with the Western Center on Law and Poverty
in Sacramento. "[It's] too much, too fast, too soon," says Cajina. A
recurring theme, Cajina has identified, is that the health plans did not
have the range of specialists in their networks to care for people with
complex or rare medical conditions.
But Emma Sandoe, a spokeswoman for
CMS, says the upcoming national experiment will have a safety hatch for
patients: they will be able to opt out of managed care if they wish.
Berenson and other experts say the
opt-out is not sufficient because it’s likely to be too daunting a
bureaucratic hurdle for many of these patients. "Fifty percent of duals
either have cognitive impairments or serious mental illness. How’s that
going to work?" says Berenson.
Lessons From California
California's plan for the federal
experiment is by far the largest of all the states applying, with
officials proposing to gradually move 685,000 duals into managed care
starting next summer. The state predicts the shift will yield $663
million in savings in next year’s
budget and additional savings in
Howard Kahn, CEO of L.A. Care, the
nation's largest public health plan with one million members in Los
Angeles County, says the effort will allow plans to knit together all
the medical care patients receive and root out physicians who are
abusing the fee-for-service system. "There's a whole bunch of really
unnecessary care being delivered and worse. Not only unnecessary, but
inappropriate and fraudulent care," Kahn said.
But California's experience of
moving the subset of people on Medicaid with disabilities into managed
care has led many to wonder if the federal demonstration project puts
the most fragile at too great a risk. A
report by the California Health
Care Foundation determined the change-over in California was rushed –
there were only seven months between federal approval in November 2010
and when mandatory enrollment began. The transition was riddled with
In interviews, insurers and legal
advocates say privacy rules prevented the health plans from receiving
complete patient records. Patients had difficulty determining if their
preferred doctors were in the plans offered to them, and those who
wanted to be exempt because of a medical emergency, like active cancer
treatment, found the appeals process onerous.
The result has been that many
patients are severing decade-long bonds with trusted doctors, while
others are being shifted to generic drugs they say are ineffective.
Some, like Juan Cameros, a 34 year-old disabled architecture student
from South Los Angeles have found themselves in a bureaucratic labyrinth
worthy of a Kafka novel.
"They refer me to [a doctor]," says
Cameros, who has a disease that makes his knees swell to the size of
grapefruits, requiring a highly specialized surgery. "But he was a
specialist on [the] spinal cord. He doesn’t do knees." Indeed, Cameros,
his lawyer says, had been referred three times by his health plan to the
same spinal surgeon. An administrative judge recently sided with Cameros
allowing him to step out of managed care. But the knee specialist who
has operated on Cameros before – and will only accept traditional
Medicaid patients – initially said he couldn’t schedule the surgery
until more paper work is filed.
Perhaps one of the biggest concerns
about the experiment centers on patients who depend on home health and
personal care aides to live safely at home.
At a conference in September in
Sacramento, Calif. of local and state health directors from around the
country, community service providers say the insurance companies that
will be contracted under the combined program have little experience
overseeing the long-term, home care needs of frail – and in many cases,
isolated – patients. Many of the insurers "wouldn’t have had in-home
supportive services," says Steven Wallace, chair of the Department of
Community Health Sciences at the UCLA Fielding School of Public Health.
This includes patients who need support every week, not just the week
they are discharged from the hospital, he says.
Those needs are not all medical.
Experts on aging say the "personal care benefit" paid for by Medicaid in
many states will now become part of a bundled payment to health
insurance companies that are ill equipped to handle to social problems
at home that often have more to do with poverty, living conditions and
Ready For The Challenge
For their part, health plan
administrators say they will be ready to meet the needs of their newest
members. "Plans are going to be covering services that they haven’t done
before," says Lisa Kodmur, program manager for seniors and people with
disabilities at L.A. Care Health Plan. "It doesn't mean we can’t. It
just means we haven't done it."
Indeed, L.A. Care has begun to
tailor its services by dispatching visiting nurses and medical
assistants to members’ homes to check blood sugar levels and blood
pressure. It also promotes a 24-hour nurse hotline.
Steven Sample is a 63-year-old
Vietnam veteran who lives in a group home in Glendale, Calif., and
suffers from a debilitating nervous condition and diabetes. Sample says
he loves the attention L.A. Care provides. "My heart was beating really
fast the other day, and I called and the nurse said to lay down," he
says. "I would have gone to the emergency room if I didn’t have the
As for Della Saavedra, the cancer
patient in Pico Rivera, she recently received some good news in the
mail: her health plan, L.A. Care, has given her permission to go out of
its network of cancer specialists and get treatment from her long-time
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