June 30, 2005

CalOPTIMA Angers Doctors With New HMO for the Neediest

Jun. 30--CalOPTIMA, which was embroiled earlier this year in a heated dispute with Vietnamese-American pharmacists, is in hot water again -- this time with doctors who say a new proposal by Orange County's MediCal agency could wrench 50,000 of their most vulnerable patients away and plop them into a restrictive HMO.

The agency's top leadership faced a room full of angry and worried physicians on Wednesday, hoping to convince them that a new HMO it hopes to launch this summer was in the best interest of patients and wouldn't harm the doctors.

But the meeting fell short of that goal, and doctors left as upset as they had been going into it.

"I'm from the government. I'm here to help. Up yours," said Clarke Smith, a family practitioner, offering his impression of the attitude conveyed by CalOPTIMA.

Many of the doctors at the meeting echoed Smith's sentiment. They said the CalOPTIMA plan would give their patients a lesser level of care insufficient to meet their abundant medical needs. And they fretted about the financial impact of the agency's proposal, which they said could siphon off a large portion of their patients -- most of whom are in fee-for-service programs, which typically pay more than managed care.

"I've been practicing for 25 years, and this is the first major threat to my livelihood that I've seen," said Narayan Devaraj, an Anaheim cardiologist who said 55 to 60 percent of his business came from patients being targeted by CalOPTIMA.

CalOPTIMA officials said the doctors' concern was based on confusion and misinformation about their new HMO, "OneCare," which is aimed exclusively at county residents eligible both for Medicare and MediCal. These so-called "Medi-Medis," or dual eligibles, are poor, elderly and disabled people considered to be the neediest of the needy.

Richard Chambers, CalOPTIMA's chief executive officer, said the agency was only trying to make life easier for this sickly population.

"Studies have shown that this population can benefit from coordinated, integrated care," Chambers said. "They have multiple, chronic conditions that no independent physician can address on his own." Chambers said these patients are facing complicated choices with a new Medicare drug benefit starting Jan. 1, and that OneCare would simplify things for them by administering all their benefits under one umbrella.

Some "Medi-Medi" patients said they would be loath to switch into an HMO.

"I like to go to the doctor I go to now, because she knows me," said Norma Taylor, 79, a Fountain Valley resident who's had four major operations in the last five years, as well as two blood clots. "She can look at me and know more than some other doctor can know after 16 tests, because she's known me for a long time."

Even if she kept her current doctor in OneCare, Taylor said, "Her concern and my concern would be whether she can refer me to specialists I may need."

The controversy started earlier this month, when doctors learned about the new HMO not from CalOPTIMA, but from Talbert Medical Group, one of the three large physician groups awarded a contract by the agency to provide care for OneCare patients.

Talbert was seeking to recruit doctors, telling them that by joining the group they would be able to keep "Medi-Medi" patients who might move into OneCare. The letter was interpreted by many doctors to mean that all their dual-eligible patients would be shifted into managed care -- an impression reinforced by another letter sent by a second medical group.

"That is not true," said Kenneth Bell, CalOPTIMA's chief medical director.

Patients can choose to stay with their doctor in the traditional fee for service arrangement, and they can also select one of the other commercial Medicare HMOs, Bell said. "The bottom line is that it's the patients' choice," he said. "And they can change every month." But doctors at Wednesday's meeting said the promise of choice was misleading, for two reasons.

First, because patients who fail to choose one of the options by October 31 will be automatically enrolled in OneCare starting Jan. 1 -- though they can change after a month. The second reason, they said, is that CalOPTIMA and the three medical groups contracting with OneCare have the wherewithal for a big public relations and marketing campaign.

"The big medical groups have the money, the MBAs, the attorneys and the public relations people to sell their kind of practice," said Smith, the family doctor. "The solo practitioner doesn't have the resources to do the P.R. work that sells our kind of practice." Bell, a trained OBGYN, said that in the end patients will almost always stick with doctors they trust. But that doesn't mean they can't join OneCare, too, he said. He urged doctors to join one of the three medical groups doing business with OneCare, so patients could have both.


--What's new: CalOPTIMA, Orange County's MediCal administrator, has applied with the federal government to start up a new Medicare HMO, OneCare.

Approval is pending.

--Who's affected: About 55,000 O.C. residents who are eligible for Medicare and MediCal. They are mostly poor, elderly and chronically ill.

--How it works now: Most of these are in a fee-for-service arrangement and choose their medical provider. The federal Medicare program picks up most of the tab for doctors and hospital care. CalOPTIMA pays for prescriptions, some transportation and some equipment.

--How it changes: Starting Jan. 1, the drug benefit for these patients will be paid by Medicare, not MediCal. To get drugs, they will need to join a Medicare HMO with drug coverage or sign up for a private drug-only plan.

Either way, there will be a new prescription copay of $1 to $3.

Patient options: 1.) Join CalOPTIMA's OneCare HMO; all benefits coordinated by one plan. 2.) Join another Medicare HMO with drug coverage; continue to get MediCal benefits through CalOPTIMA. 3.) Stick with fee-for-service; sign up for a standalone drug plan; continue to get MediCal benefits through CalOPTIMA.

--Timeline: Decision on OneCare is expected soon, and it would begin enrolling members Aug. 1 and providing services Sept. 1. Those who don't choose by Oct. 31 would be enrolled in OneCare with a Jan. 1 start date.

But they can change after a month and monthly afterward.

--Why the fuss: Doctors believe patients will be forced or convinced to join an HMO, which they say will provide inadequate care. Doctors also could lose business unless they join a OneCare medical group.

FOR 'MEDI-MEDI' PATIENTS: For more information about changes affecting dual Medicare-MediCal beneficiaries, or about the new Medicare prescription drug benefit: 1-800-MEDICARE, or www.medicare.gov CalOPTIMA, (714) 246-8800 Health Insurance Counseling and Advocacy Program (HICAP), (714) 560-0424 Your personal physician; be sure to discuss these changes with him/her.


To see more of The Orange County Register, or to subscribe to the newspaper, go to http://www.ocregister.com.

Copyright (c) 2005, The Orange County Register, Calif.

Distributed by Knight Ridder/Tribune Business News.

For information on republishing this content, contact us at (800) 661-2511 (U.S.), (213) 237-4914 (worldwide), fax (213) 237-6515, or e-mail [email protected]