California patients struggle to transition to managed care system

One year ago, California began moving certain Medi-Cal patients into a managed healthcare system with the goal of saving money while better coordinating treatment.

But for some of these low-income seniors and disabled patients, the transition has been anything but smooth, forcing severely ill patients to give up their doctors, delay treatment and travel long distances for specialty care.

As of this month, the state has transitioned 333,000 people, many with diseases such as multiple sclerosis, lupus and metastatic cancer. State health officials said managed care oversees all of the patients’ treatment and guides them through the healthcare system, helping prevent unnecessary procedures and hospital visits.

Patients could apply for temporary exemptions if they wanted to stay on a fee-for-service plan, where the state pays doctors based on the specific treatment provided instead of a managed care general rate that is usually less. But the patients had to meet a high bar: They had to be in ongoing care for a serious illness and any change could cause their condition to deteriorate.

“The criteria is met by very few people,” said Susan McClair, senior medical consultant with the state Medi-Cal Managed Care Division.

Nearly 18% of the 19,684 people who applied for exemptions between June of last year and April were approved, according to the state. Almost 32% were denied and the rest had their papers sent back as incomplete.

Maria Blancarte, 61, who has rheumatoid arthritis and must use a wheelchair, spends about 22 hours a day in a hospital bed at her Eagle Rock home. She lives in constant pain. Blancarte applied for an exemption with the support of her doctor, who submitted a letter saying that she needs monthly evaluation, adjustments in medication and physical therapy.

“The disease renders her totally and permanently disabled,” the letter said. “She should be allowed to continue her medical follow-up with the physicians who have cared for her in the past many years.”

The state Department of Health Care Services denied Blancarte’s application, saying her medical condition didn’t qualify her for an exemption. The state did let her stay with her doctor for one year, but Blancarte said he fears that the state won’t pay him for all the services he provides.

“I don’t know who made up this system, but it has no heart in it,” she said. “It’s one-size-fits-all managed care.”

Desa Stanojevic, who also has rheumatoid arthritis and kidney stones, said she was also denied an exemption and told she could no longer see her specialist at UCLA. “I felt defeated,” she said. “You have to be almost dying or critically ill” to get an exemption.

The state aggressively monitors the health plans and investigates specific complaints, said Margaret Tatar, chief of the Medi-Cal Managed Care Division. The state is committed to ensuring that patients’ care is not disrupted, and patients who have an existing relationship with a physician can request to stay with that doctor for one year, she said.

Between June 2011 and March, 8,963 requests by patients to stay with their current physicians were granted and 1,582 were denied.

But for most patients, keeping them on fee-for-service plans doesn’t work well for them or the state, health officials said. “We believe in the benefits of that coordination,” Tatar said.

Toni Vargas, staff attorney at Neighborhood Legal Services, a legal advocacy organization, said the state took a “hard line” by denying exemptions. And once the patients were in managed care, many didn’t receive the treatment they needed, she said.

“They were pushed in a system that wasn’t ready to take on this population,” she said. “In concept, [managed care] is a good thing. But the concept and reality aren’t exactly in the same place.”

Vargas said the process is “frightening and confusing” for patients, many of whom also have mental health issues. “They don’t know or can’t figure out how to use the plans.”

Shifting patients into managed care has been a “disruption” for many, in part because there simply aren’t enough specialists who will accept patients on Medi-Cal managed care, said Liz Forer, executive director of Venice Family Clinic. The patients’ complicated illnesses overwhelmed family practice providers at Venice Family Clinic, Forer said. They weren’t equipped to treat patients with end-stage organ disease, multiple types of cancer or Parkinson’s disease.

“They know when to raise their hands and say, ‘I am in over my head here,’” Forer said. “That is what they are saying ... It is not just one illness. It’s two or three or four or five, on top of each other.”

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