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San Mateo to lead health program aimed at reducing red tape

/ 09:19 AM February 07, 2014

Official explains integration of Medicare and MediCal health services. PHOTO BY HARVEY BARKIN/INQUIRER.net

BURLINGAME—San Mateo County is leading California’s initiative to integrate the fragmented services for those who qualify for both public health insurance plans Medicare and Medicaid (MediCal in California). Ten percent of the county’s 178,118 Asians are Filipinos.

The pilot program, to be administered by the Health Plan of San Mateo (HPSM), will roll out by April 1 this year.

The goal is for the “dual qualified” to have “full access to seamless, high-quality healthcare and to make the system as cost-effective as possible.” This was revealed last Wednesday at a New America Media (NAM) news briefing at this city’s public library Lane Community Meeting Room.

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HPSM will roll out the program first because “it is the only plan that accepts MediCal,” said Medical Director Dr. Fiona Donald.

Cal MediConnect is essentially a Swiss Army knife that can cut through paper bureaucracy and the long wait for appointment schedules caused by ambiguity and uncoordinated information. Think of it as a more user-friendly USB storage device for people who can’t deal with data management.

Imagine one card that does it all. The Medicare card for the visit to the doctor, the pharmacy card, the MediCal card for the optometrist and the card with essential access information usually given by a social worker to beneficiaries—the adult and aging card, Meals-on-wheels and Redi-wheels (if qualified).

The Program promises to do these and more. Tricia Vinson said, “If three extra hours of in-house service can keep a patient out of a Skilled Nursing Facility (SNF), the Program will provide for it.” Vinson is directing attorney at Legal Aid Society of San Mateo County.

“If you need a ramp (for the wheelchair-bound) or grab bars (for those with crutches or walker) in your shower, the team can decide in your favor,” added Vinson. “And the Program also gives respite to the spouses and others who provide care. Just for those who need a break—we can do that.”

“We’ve been in the community since 1987 and we’re founded by a group of physicians who provide MediCal services for our members in conjunction with the government. We coordinate services with the low income and the historically underserved in the county. We have integrated county, state and federal benefits and resources. This really puts us in an ideal position to administer HPSM.”

The program, Cal MediConnect  (or Medi-medi to insiders), will also be implemented in Los Angeles, Orange, San Diego, Riverside, San Bernardino, Alameda and Santa Clara.

Some counties may roll out their own version of the Program as late as January 2015, said Vinson. NAM Executive Director Sandy Close said, “And what California does, the rest of the country does.”

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Combining both benefits

Cal MediConnect will include all benefits currently available under Medicare (Part A for the hospital, Part B for the doctor and Part D for the pharmacy).

It will also include all benefits currently available under MediCal including long term services and supports, like in-home support services, multipurpose senior services program (providing licensed nurses for patients who live independently, but in San Mateo County, this program is filled and there is currently a waiting list ). The county will still determine hours, but beneficiaries retain the right to choose their own provider.

Noteworthy additions to Cal MediConnect benefits include support for adult dental (which was cut years ago by MediCal), vision and transportation. And since patient data and information will be coordinated, there will also be specialty mental health services. This would be useful since depression and anxiety often come with chronic medical issues. Mental health professionals in the program will then have a better capability to treat patients when provided with their current histories.

But, to the disappointment of the team, said Vinson, those with developmental disabilities are excluded from Cal MediConnect. Those with End Stage Renal (ESR) disease are included in San Mateo and Orange counties but not in the other counties.

Those in the PACE program (an all-inclusive care for the elderly), the HIV/AIDs Waiver and Kaiser Medicare Advantage programs are eligible only if they choose to un-enroll from those programs.

Help for the non-English speaker

When a patient is enrolled in the Cal MediConnect program, Dr. Donald said, “The main thing that happens is that the patient has a single point of contact to help her navigate the system and the benefits to which he is entitled.”

The Program would reach out to work with the patient usually through a nurse or case manager, who would also most likely be fluent in the patient’s native language.

Filipino caregiver Gladys Wilkom wished the Cal MediConnect had “happened sooner.” Wilkom takes care of her dual eligible father. Three years ago, he was diagnosed with aneurysm, among others.  She helped him by reading through the tedious literature of his medication and filling up forms. But he refused his medication, prompting his doctor at one time to say, “I give up on you!”

This echoed Dr. Kenneth Tai’s sentiments. The Medical Director of North East Medical Services in San Francisco said, “85 percent of my patients don’t speak English. Usually, during a visit, patients get a standard letter in English from Medicare or the Center for Medicare and Medicaid Services (the agency that oversees the state administration).”  Non-English speaking patients, already overwhelmed by medical instructions and regimen, have to put up with the mystery of English.

“The other difficulty is that we physicians don’t get a report of where the patient has been treated recently. We get those way, way later. If I had the feedback from HPSM, I can easily get the patient to my clinic within a week after discharge from the hospital. A follow-up needs to be done because the patient may not have gotten the hospital-prescribed regimen right. And we also have to be culturally sensitive, specially to people who don’t believe in western medicine.”

OK to opt out

There is no lock-in for beneficiaries enrolled in Cal MediConnect. Opting out can be done after or during enrollment. Duals who opt out will continue to have all their current Medicare benefits.

Duals who stay with Cal MediConnect may continue to see their existing Medicare doctor for up to six months and use their MediCal provider for a year even if the provider does not join the Cal MediConnect network.

Dr. Tai explained that the most probable reason a doctor won’t join the network is that doctor’s physicians’ group restrictions. A private physician may balk at the reimbursement negotiated by the Program. MediCal recently cut it by 10 percent. Some colleagues in private practice say $18 per visit is not sustainable.”

Vinson added that the challenges for Cal MediConnect to be sustainable are two-fold. “Cost-saving targets could threaten the promise of improved care and that savings may not be realized right away. But the aggressive timeline goals of the state raise concerns about the Program’s readiness and continuity in some counties.”

There are about 1.1 million dual eligible in California. The state plans to enroll 456,000 into the pilot programs. An estimated 200,000 of those will be in Los Angeles. Seven out of 10 duals are 65 or older, most of them women. One out of three dual eligible is a youngster with disability.

San Mateo County has approximately 12,371 eligibles for the Program. About 4,547 are scheduled for the April enrollment. These so called passively enrolled dual eligibles can opt out of the Program.

The HPSM currently has several other programs. The first, in place since 2006, is the Care Advantage, a special needs program for dual eligibles numbering about 8,600. They also have the Health Works Program for people who provide in-house services.

Their MediCal Program has about 85,000 members. Their Ace Program provides coverage for most adult undocumented aliens in the county, administered through the San Mateo Medical Center. Last is the Healthy Kids Program for those under 19.

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