Medi-Cal Managed Care and Women's Health
September 9, 1997
By Julianna S. Gonen, PhD
Mary Ellen Hamilton, Vice President of Public Affairs for Planned Parenthood of San Diego and Riverside counties, opened the program by welcoming attendees and participants. Martha Romans, Director of the Jacobs Institute of Womens Health, recapped the first two seminars in the series, which had focused on consumer concerns and on the various stakeholders in the marketplace. Helen Rodriguez-Trias of the Pacific Institute for Womens Health added that she hoped that the findings of the series would "allow womens voices to converge in force" and have an impact on the work of the ongoing Governors Task Force on managed care.
The State Perspective
Carolyn Castillo from the state health department opened the program by noting that she has "lived and breathed managed care" for some time now with the implementation of the Medi-Cal managed care program, and proceeded to outline some of the challenges posed by this implementation. She observed that womens health issues within the Medi-Cal program go beyond clinical concerns to include issues related to access. California instituted its Medi-Cal expansion plan in 1993 after decreased reimbursement rates had led to a decline in the number of providers willing to treat Medi-Cal patients. The goal was to create a more effective and efficient delivery system that would emphasize preventive and primary care and early intervention for 2.8 million eligibles. Other program principles included creating a quality assurance system, the development of culturally and linguistically appropriate health services, purchasing care from organized managed care plans under capitated, at-risk arrangements, and the design of a system to ensure the integration of public and private health care service delivery. The state has introduced managed care to the Medi-Cal program through several different models: county organized health systems (where enrollment is mandatory for all beneficiaries), geographic managed care (where a number of different health plans compete for enrollees), and the two-plan model (consisting of a mainstream MCO and a local initiative comprising community stakeholders and providers). Ms. Castillos presentation focused primarily on the two-plan model, which was the focus of the 1993 managed care expansion plan, while other speakers on the panel described experiences under county organized health systems and geographic managed care. The audience thus learned about all of the various ways in which Medi-Cal managed care is being implemented throughout the state.
Ms. Castillo reviewed data on Medi-Cal eligibles by delivery model over the past five years which showed that managed care still covers under half of the overall Medi-Cal population. She also showed the gender breakdown of Medi-Cal beneficiaries in all aid categories; while the numbers are even during childhood and adolescence, women are a greater proportion of beneficiaries during their childbearing years and also in the elderly population. Overall, adult women make up 33% of the Medi-Cal population, while adult men comprise 15%; children make up the remaining 52%.1. There are currently 5.2 million Medi-Cal eligibles in the state.
In the balance of her presentation, Ms. Castillo focused on the two-plan model recently implemented in twelve California counties. The state actively solicited public input when creating policies for the managed care expansion plan, and devised a system which diverged somewhat from traditional managed care models, specifically in allowing for access to certain services out of network. Clinical services covered under the model for which health plans must reimburse out-of-network providers include family planning, STD treatment, HIV testing, nurse midwife services, and immunizations. Health plans are required to contact new enrollees within 120 days to offer health assessments and preventive care. The model also has access policies with regard to language and culture, reading proficiency, transportation, confidentiality of sensitive services, and educational services.
Following Ms. Castillo, John Dunn, Executive Director of Planned Parenthood for Orange and San Bernardino Counties, described his experiences as a community-based provider under CalOPTIMA, the county organized health system of Orange County which has been in place for the past two years. He stated that there are some unique features to CalOPTIMA that have proven beneficial for womens health and good for essential community providers such as Planned Parenthood, largely due to a commitment on the part of the CalOPTIMA board and staff to ensuring the continuation of the pubic health safety net. Success has also come in part because the physician-hospital consortia, the "hybrid health plans" brought together as part of the system, have been directed to work with community providers so that these local providers could "continue to be players." This meant that women could either continue to access their traditional providers or select from a wide array of new health plans. The system has approximately 270,000 members and provides a wide choice of plans and providers, and contains strong support for reproductive health services. Provider choice and definition of a broad scope of services for family planning and obstetrics have improved under CalOPTIMA, as has monitoring of perinatal providers and services. Beneficiaries have "voted with their feet" and moved around to find providers that best meet their needs, sometimes abandoning the providers they had previously used. Having enforcement authority vested in the local organization (CalOPTIMA) has helped in improvement of services and also in supporting the provision of out-of-plan services, such as family planning services for which freedom of provider choice is actually a federal requirement.
The system is of course not perfect, however, and Mr. Dunn outlined some areas where improvement is needed. While services have improved, the complexity of the system can be quite challenging for patients and limit their access, and cultural, language, and transportation barriers remains high as well. This may improve over time, as members find providers who meet their particular needs. One of the biggest problems has been that of religiously-based providers in the area of reproductive health services, as these providers generally have internal directives proscribing these services. Many of these institutions are highly-regarded providers in the community and are therefore important players for CalOPTIMA and Medi-Cal beneficiaries. While these providers are not required to provide these services directly, as participants in the Medi-Cal program they must refer their patients elsewhere if desired by the patient, and this communication has been found lacking. One observed result has been an increase in the number of second-trimester abortions being performed, ostensibly as a result of delays in referrals, which increases risks to women. CalOPTIMA has been working closely with Planned Parenthood on solving these communication and referral issues.
One of the challenges for health care providers under Medi-Cal managed care has been the lack of consistency among the different Medi-Cal managed care models across the state, a problem that has been ameliorated considerably in Orange County due to the existence of CalOPTIMA. Another challenge has been the costly billing and collections procedures and increased receivables due to the large number of plans with which local clinics and providers must deal, and difficulty collecting reimbursement from these various plans for the provision of out-of-plan services. There is also greater complexity at the medical center level, as they must deal with capitated lab contracts, prescription limitations, and pre-authorization issues with which they previously did not have to grapple. Ultimately this could lead to fewer providers and therefore reduced access for beneficiaries, as smaller community-based providers struggle under this new environment and must either merge with others or cease operation.
The most successful aspects of the system are better access to preventive care and reproductive health services as a result of state mandates, more coordination and integration of services (due in part to new cooperation between hospitals and safety net providers), more choice of providers, and improved relations between hospitals and family planning providers.
Mr. Dunn closed by noting that there are several lessons that private payers and health plans can learn from the experience of Medi-Cal and CalOPTIMA (although he was skeptical that the commercial insurance industry would embrace many of these features). These include allowing out-of-plan access for certain services (especially family planning), instituting linguistic and cultural competency requirements, clarifying and standardizing the scope of family planning services, comprehensive perinatal support services programs, and coverage for every form of FDA-approved contraception.
The Geographic Managed Care Model
Yolanda Partida from the San Diego County Department of Health Services then continued with a presentation on Healthy San Diego, the countys geographic managed care model. She noted that 13% of San Diegos population is in the Medi-Cal program, and that the county has had experience with Medi-Cal managed care since the early 1980s. The county also has considerable experience on the commercial managed care side, with over 50% of the commercial population enrolled in managed care. Healthy San Diego is one of two geographic managed care models in the state, and is an organization comprising several health plans designated by the county as eligible to serve Medi-Cal beneficiaries. The countys role is to guide beneficiaries when choosing a managed care option, as previously there had been considerable confusion on the part of Medi-Cal eligibles when managed care options were introduced. While enrollment in managed care is voluntary, it is the default option if a beneficiary does not select a plan. Healthy San Diego includes four Knox-Keene licensed MCOs, each of which provides slightly different benefits (both inpatient and outpatient), and two primary care case management (PCCM) plans. Helping beneficiaries understand the various choices open to them has been a major challenge. Healthy San Diego has focused on providers to help alleviate some of the confusion by publishing a newsletter aimed at providers and by having Healthy San Diego enrollment forms available in individual provider offices. While mental health services for Medi-Cal are addressed separately through very different models at the state level, the county is attempting to integrate these services with medical care at the local level. Children with special needs and their fluctuating eligibility are a priority population for Healthy San Diego and Medi-Cal.
The geographic managed care model has increased choice for beneficiaries but problems remain with delivery. While the managed care plans are ostensibly integrated delivery systems, most are in fact "contract networks" which require complex referrals and authorizations for the provision of care. These networks also engender a large amount of administrative overhead as a by-product. While Medi-Cal has been good for pregnant women, there is concern about women who are not pregnant or do not have children and therefore have less access to services, as well as undocumented women for whom prenatal care benefits will be terminated shortly due to the passage of recent legislation. These women will likely be absorbed by other safety net providers or be seen in emergency rooms. Ms. Partida observed that in the Medi-Cal program the state is both the purchaser of care and the provider of last resort; this latter role is shifting under welfare reform and changes in the health care delivery market. In general there is concern that managed care, while population-based in terms of enrolled lives, is not in fact community-based with a needed focus on social, economic and cultural context issues that have a direct impact on health. Strategies employed by health plans tend to be geared toward a middle-class population and need to be adjusted for newly-enrolled populations.
The health department has an important role to play as the Medi-Cal population is transitioned into managed care, particularly in terms of setting standards for health plans that will serve this population. These standards must reflect the diversity of the enrolled population. The state is moving from a regulatory stance to a contract-based position with regard to health care providers. More data is needed on whether outcomes are improving under managed care plans and what services are actually being delivered. It is important that local input is included when devising delivery systems and programs, so that the local market and local consumer interests are taken into account.
A County-Organized Health System: CalOPTIMA
The final speaker was Carole Steiner, Director of Health Services for CalOPTIMA, the county organized health system described earlier by John Dunn. CalOPTIMA began operations in October 1995, and currently has a membership of approximately 218,000 beneficiaries. (This is actually lower than anticipated due to current low levels of unemployment in Orange County.) Certain aid categories such as aged, blind, disabled, and long term care are enrolled on a mandatory basis; this adds a different dimension to this system from programs which only enroll AFDC beneficiaries. The delivery system is a combination model, with 5 HMOs, 13 hospital-physician consortia (created specifically for CalOPTIMA to serve Medi-Cal beneficiaries, with mandated inclusion of traditional providers and community clinics), and CalOPTIMA Direct, a modified fee-for-service program administered directly by the agency. This program serves as a transitional program for the mandatory managed care aid codes as they move into health plans; Medicaid/Medicare dual eligibles and shared-cost beneficiaries remain in CalOPTIMA Direct on a permanent basis. Eligibility is determined solely by the county and not by the CalOPTIMA agency. Once beneficiaries have applied and been admitted to the system they go through an enrollment process with CalOPTIMA, either choosing a health plan or being autoassigned. Autoassignment is the default option for AFDC recipients and for those with Medicaid as their primary coverage. Unlike the two-plan model, CalOPTIMA controls enrollment with the health plans; the contracting health plans are not allowed to enroll members directly.
In terms of the demographics of the enrolled population, women tend to outnumber men in each age bracket; the majority of overall beneficiaries are found in the under 21 age group. In the long-term care aid code category, women comprise nearly 70%. Certain services that are carved out of CalOPTIMAs program include California Children Services (CCS), dental care, mental health, substance abuse, and CHDP. While many of these separate programs are good, these carve-outs tend to fragment care for the beneficiaries. On the other hand, there are several features of the services provided by CalOPTIMA health plans (and CalOPTIMA Direct) that are improving access and health status. These include health education classes, disease state management programs, case management, and perinatal support services. There are of course cultural, linguistic and literacy barriers that remain to be worked out. Other issues with which the agency grapples include the greater incidence of depression among women; while mental health services are carved out, over 60% of depression diagnoses are treated at the primary care level, for which CalOPTIMA is responsible. As a result they are developing a project focusing on giving the primary care network guidelines on detecting and treating depression. CalOPTIMA is also responsible for covering the costs of mental health drugs, even though mental health services are otherwise carved out.
Ms. Steiner went on to focus in particular on the Perinatal Support Services (PSS) program, which was modeled after the states existing CPSP program. This program has become a model of how perinatal services should be delivered; the program is available to all women in the CalOPTIMA system, it incorporates elements of case management, and 90% of assessments are done in the members own home. The comprehensive assessments include obstetrical, psychosocial, nutritional, and health education elements, and the members profiles are provided directly to the obstetric provider. The PSS staff are bilingual and bicultural, and include both lay health workers and licensed providers; the former perform assessments only on low-risk pregnant women. Overall, just over half of pregnant members in the CalOPTIMA database were classified as low risk; 31% were determined to be high risk, with the balance undetermined. Risk factors considered are both clinical and psychosocial. The PSS program has a special case management program for pregnant teens.
Policy concerns include the de-linking of assistance and medical coverage under welfare reform. As a waiver program, CalOPTIMA is very sensitive to changes at the federal and state levels. On the other hand, changes that will mandate pap smears and mammograms hold the potential to decrease cancer rates among their enrolled women. Socioeconomic issues with policy implications have direct relevance to the delivery of health care to the Medi-Cal population, as low-income women often lack the resources to manage their own health care and to make sophisticated choices about new health plans.
Ms. Steiner closed by noting some things about the program that seem to work well, such as proactive contact with the members, who really dont know how to navigate the system on their own. This outreach needs to take place in the members spoken language and in an environment familiar to them. For teen members, peer groups have proven a successful format. And finally, health care providers themselves also need orientation to the programs available to Medi-Cal managed care patients in order to facilitate their access to these services.
The program was then opened up to questions and comments from the audience. Dr. Rosalyn Baxter-Jones, an ob-gyn from San Diego, commended the CalOPTIMA program and questioned Carole Steiner about how the information from member health risk appraisals is used by providers and whether such appraisals are done on non-pregnant women. Ms. Steiner responded that CalOPTIMA has been working on educating providers about the programs available to Medi-Cal enrollees. A questioner from Childrens Hospital asked whether the CPSP program is carved out from the health plans and provided directly through CalOPTIMA, or whether the plans provide these services as well. Ms. Steiner responded that the CPSP dollars were not included in the overall health plan capitation rate out of a concern that this would reduce the incentive for the provision of the services. If plans choose to provide the services, they receive an additional capitation rate; otherwise the members receive those services directly from CalOPTIMAs PSS program. The same questioner then asked if any shift had been detected in beneficiaries using traditional safety net providers versus new providers who have entered the system. Ms. Steiner said that they only really had anecdotal information, but that they have not been hearing complaints from enrollees about access problems or long wait times. She added that enrollees can change health plans on a monthly basis but that the actual switch rate is less than 2%. And finally this questioner inquired how it was that religiously-based health plans could obtain Medi-Cal contracts without agreeing to provide the full range of services required by the state. John Dunn responded that while they are required to provide the services, they can do so through sub-contracts and do not have to provide them directly. Problems have been observed, however, with providers documenting provision of services that are not actually being provided. A solution devised by CalOPTIMA has been to carve out a portion of the health plan capitation rate for those religiously-based providers and provide a sub-capitation to Planned Parenthood to provide those services that the religious providers decline to provide. Communication about the availability of these services by primary care providers who are bound by these religious directives, however, often remains poor. This has resulted in delays for some women seeking family planning services or termination of a pregnancy. Carole Steiner added that the physician-hospital consortia are not Knox-Keene licensed health plans, but really hospital systems created expressly for CalOPTIMA contracting.
Asha Chopra, medical director for two IPAs in the inland region, commented that she was "stunned" by the complex array of Medi-Cal managed care arrangements found across the different counties, and asked specifically about the CPSP program and family planning services. She stated that their IPAs, which provide services for the Inland Empire Health Plan (IEHP) local initiative, are having difficulty finding family planning providers willing to provide the services required by the Medi-Cal program. Those that will provide the services are geographically spread out, making access difficult for women, and the religious and political barriers are "absolutely rampant" in the inland area. For this quandary she was seeking any suggestions. Dr. Chopra also inquired about the availability of Depo-Provera at the family planning service level. John Dunn responded that "the answer to both questions is Planned Parenthood" and that they are currently working on a contract to provide services through IEHP, including all FDA-approved methods of contraception. Planned Parenthood is also attempting to sub-contract with as many of the small medical group providers as possible to facilitate direct access for beneficiaries. Both Mr. Dunn and Dr. Chopra agreed that it is difficult to provide certain more expensive treatments, such as Depo-Provera, under capitated reimbursement. Yolanda Partida added that this issue illustrated well how the delivery of health care services is a distinctly local matter, and that one must be in the affected community to recognize the unique issues that affect service delivery. Some counties have a local entity like CalOPTIMA that serves as an intermediary with the state, while others such as San Diego deal with Sacramento directly; this affects how informed the state and the Medi-Cal program are about problems that arise locally. Carolyn Castillo added that the state is limited in setting their capitation rates by the actuarially-determined fee-for-service upper limit, which is a federal requirement. She noted that the state has indeed receive a great deal of notice regarding perceived inadequacies in the current rates. John Dunn further added that this issue also demonstrated the mixed effects of a capitated system; while it can be used to drive integration and a prevention focus, it can also result in some service restrictions that are driven by cost considerations. Francine Coyteaux of the Pacific Institute stated that the issue also highlighted how the advent of newer technologies affect consumer demands and health care costs; beneficiaries are now attempting to gain access to services that were not included in past benefits and therefore in the fee-for-service upper limit cost estimates, which seems to call for a revision of these estimates.
Mitch Besser of Ob-Gyn Consultants in San Diego asked Ms. Partida about the 25% uninsured in San Diego and their breakdown by working poor and residency status, and how they will be affected by recent passage of Proposition 187 and welfare reform. She responded that most of these uninsured are working poor with no health insurance, which affects womens access to care and their health outcomes.
Sarah Samuels of the Pacific Institute asked that the group step back and look at the larger question of whether managed care is benefitting women, and what types of evidence we would need to document the benefits and/or harms. Rhoda Nussbaum from Kaiser Permanente began by responding that there is some evidence that some aspects of managed care such as increased access to preventive services have been beneficial, but that in general the health care system is deficient in knowing how to truly measure outcomes. We measure process, but do we really know what value is being derived? The new era of managed care is mandating the integration of care, but presently there is a great deal of short-term profit-driven decision making that is not necessarily in the best interest of womens health. Yoland Partida responded by adding that rather than taking an "insured lives" approach to providing things like preventive services as a product to certain eligible people, health plans should take a more community-based approach. Carole Steiner added that at some point the multiple streams of funding that provide services to populations through public dollars should be better integrated and rendered more efficient. Carolyn Castillo asserted that since managed care is here to stay, the question is how to adjust the system to produce the outcomes that we seek. While the Medi-Cal managed care model found in California is "incredible" and not likely to be found anywhere else, it is just that, a model, and the challenge lies in implementation. The model was in fact designed to allow for community adjustment, which has occurred, as was demonstrated amply here today. She added that health plans with Medi-Cal contracts are required to submit a large amount of data to the state for the purpose of monitoring the delivery of care, which should help drive improvements.
Dr. Chopra asked about how to better integrate care, especially for women, whose care has been particularly fragmented, beginning with obstetric care. There is a disconnect between the policy of providing a wide range of care and the fragmented delivery of these services. John Dunn agreed that often there needs to be better alignment of service delivery policy and payment policy. There are some services, such as family planning, that simply dont lend themselves well to capitation. Yoland Partida noted that on the other hand the state has done a good job at including services in the Medi-Cal contract, and that the existence of managed care has in fact facilitated discussion of problems in service delivery and quality, discussions that did not occur under the fee-for-service system.
Heather Ion, a medical anthropologist and ethicist, complimented CalOPTIMA on its prenatal care program. She went on to note that the notion of fragmented care has been mentioned frequently today, and asked how we are going to get comparative data on different models to see what works best. Carolyn Castillo concurred in the concern, noting that the state has an entirely separate program of managed care for mental health. Ella Kelly of the Pacific Institute responded that UCLA is leading an effort to evaluate various managed care models in place throughout the state; this will, however, be a long-term process. Helen Rodriguez-Trias added that at the previous seminar in this series, data presented by Helen Schauffler indicated that HMOs were doing better at delivering preventive services to women, but that indeed the area of outcomes indicators needs a lot of work. Development of such indicators must be a multidisciplinary effort with substantial community input. Yoland Partida cautioned that individual-level encounter data alone may not yield sufficient information on quality, and that community-based health needs assessments should be used; the challenge is how to use this information to hold health plans accountable.
Elisa Hammond, executive director of FPA Medical Group of San Diego, asked Yolanda Partida about the voluntary managed care enrollment process that has proven confusing for beneficiaries. As a provider she has seen disruptions in continuity of care as enrollees have defaulted to providers other than those they have traditionally seen. She also asked when mandatory enrollment was likely to hit San Diego. Ms. Partida responded that the target date for mandatory enrollment is June of 1998. She went on to state that Healthy San Diego is proud of its enrollment process, which employs twelve counselors who speak a range of languages. The larger problem is the arrival of a new conceptual paradigm with which beneficiaries are not familiar, and these complexities will indeed take time to work out. The number of beneficiaries actively choosing their own plan is steadily increasing; the default rate in San Diego County is under 10%, the lowest in the state. Claudia Garcia, an enrollment worker for the county department of social services, described some of the challenges faced when trying to present health plan information to Medi-Cal beneficiaries who are ill-equipped to make the choices now available to them. She often advises these beneficiaries to ask the doctor or clinic with which they are comfortable and familiar which health plan the provider participates in, to help them in making a choice, as the county enrollment workers are proscribed from making decision for beneficiaries. Francine Coyteaux commented that this should remind us to be mindful of the client perspective as we undertake these discussions in addition to focusing on the systems and how to make changes.
Fran Teplec, Clinical Outcomes Manager for womens and childrens services at Tri-City Medical Center in Oceanside, returned to an issue discussed earlier, the pending proscriptions on provision of care to illegal aliens. This will have a major impact on the ability to measure outcomes of prenatal care and obstetric care. She asked how Medi-Cal would deal with maintaining services to this population when changes come about. Carolyn Castillo conceded that many at the state level do not agree with these particular policy changes, and that state legislators need to be pressured. Carole Steiner noted the irony that this is one area for which we do have data showing positive outcomes and it was nonetheless ignored in crafting policy. This renders dubious the notion that further data will be used to intelligently inform future policy.
A brief discussion of hospital lengths of stay for childbirth ensued, following which Yolanda Partida noted concern about the tendency of legislatures to set standards of care. John Dunn followed on that by again emphasizing that when creating capitated systems, dollars must be aligned with the desired outcomes. When there is considerable enrollee turnover, as with the Medi-Cal population, health plans do not have a clear incentive to provide preventive care. Thus capitation really only makes sense when enrollees are going to have a long-term "medical home" and relationship with a provider. Given these realities, such services must be mandated in a capitated system or providers simply may omit them. Ms. Partida further added that enrollees in a public system should not be viewed in terms of dollar investments when it comes to these preventive services, whose provision should be a shared societal value.
The importance of public/community/local input when devising systems.
The importance of allowing for out-of-network access for some services - e.g., the importance of the public health safety net.
Sometimes commercial plans and payers could stand to learn from successful public programs models, such as CalOPTIMA.
The downside to increased choice is often bewildering complexity for beneficiaries who are not sophisticated health care consumers; this can pose daunting access barriers.
Health plan programs and standards must be tailored to reflect the diversity of needs of public beneficiaries.
The separate treatment of mental health from physical health services by the state and therefore by the various county programs leads to fragmentation of care and has required creative solutions on the part of the local initiatives.
Little is known about the outcomes of various delivery models or even specific services; indicators need to be developed from a multidisciplinary perspective and with community involvement.
Political considerations often override the creation of sound health policy.
1. 1995 data.