State Set to Move Rural Seniors, Disabled to Medi-Cal Managed Care

By David Gorn, California Healthline

About one month from now, the state is launching a program to shift a new set of Medi-Cal beneficiaries into Medi-Cal managed care plans. This time, the state is focusing on a shift in care for some of the frailest patients in rural counties.

On Dec. 1, about 20,000 Medi-Cal seniors and persons with disabilities in 28 rural counties will make the switch to managed care plans. It's a continuation of an extended effort by the state to expand Medi-Cal managed care to rural areas, said Mari Cantwell, chief deputy director of health care programs at the Department of Health Care Services, which oversees Medi-Cal.

"We started the rural expansion about a year ago, starting with non-disabled adults and children in 28 counties," Cantwell said. "Still pending are the population of seniors and persons with disabilities (SPD's). That's not a very large number of people in comparison, about 20,000 people."

However, it is a population with some big challenges, Cantwell said -- people with multiple conditions, medications and providers. That makes the transition tricky -- and also points out its importance, she said.

"From our perspective, our managed care plans are able to provide better integrated care, they are doing risk assessments to see where the gaps in care might be," Cantwell said.

"It is really about improving care so they can have their health plan help them navigate the system," she said.

Among many of these frail beneficiaries, though, there is deep fear about what's about to happen, said Steve Barrow, president and CEO of Advocates for Health, Economics and Development, a not-for-profit advocacy group for underserved areas, including rural California counties.

"Just put yourself in their place," Barrow said. "You establish specialty care in some place like Redding or Reno, and if you can't go to the same place, it would be pretty scary."

Rural counties have an alarming lack of specialty providers, Barrow said, so people might have difficulty finding one who treats their particular problem -- or set of problems -- within a manageable distance. And it's not just beneficiaries who have concerns about this particular transition, he said.

"For the provider, it's scary because you're not sure you can handle all of these patients' problems [at managed care reimbursement rates]. And for health plans it's scary taking on these complex patients, because they're wondering now, "How do we not lose our shirts on these patients?," Barrow said. "There's plenty of fear to go around."

Rural care is more challenging because of the distances involved, on top of the scarcity of providers, Barrow said.

"In rural areas you have extreme difficulties to establish specialists in the first place. There's also a huge shortage of primary care physicians in rural areas," Barrow said. "I mean, the landscape is already difficult for people who are healthy."

Add in the inexperience of rural counties in dealing with managed care and you have a situation that's more difficult than any other state transition to Medi-Cal managed care, Barrow said.
"They call it a safety net for a reason," Barrow said. "It's very thin. It may be a small number of people, but this is big impact."

Cantwell said the department is aware of all of these concerns and officials hope to make this transition smoother than some of the others have been.

"We certainly have applied lessons learned," Cantwell said. "We are making sure health plans have data on people in advance of being enrolled in the plans. We are making sure there is more clarity on the continuity-of-care provision."