In a report released Tuesday, California State Auditor Elaine Howle upbraided the state Department of Health Care Services for its failure to ensure Medi-Cal beneficiaries have adequate access and quality of care in 18 rural counties stretching from Inyo to the south to Tehama and Plumas in the north.
Howle looked into the welfare of these Medi-Cal beneficiaries at the behest of the Joint Legislative Audit Committee, which wanted to know whether the patients were receiving care comparable to their peers around the state since being transitioned into managed care plans from fee-for-service plans during the Medi-Cal expansion in 2013.
In 67 pages of chapters, charts and summaries, the auditor’s findings were plain and unwavering: No, they do not.
The managed care plans, run by Anthem Blue Cross and California Health & Wellness, failed to meet a significant number of minimum quality metrics set out by the Department of Managed Health Care, Howle wrote. Of 22 metrics in 2015, Anthem fell below the bar on 9.5 and Health & Wellness on 10.5, compared with 4.1 for plans in the rest of the state.
Last year, Anthem had brought that down to 5 and Health & Wellness to 6 of 21, Howle noted, but their peers in the rest of the state also narrowed the gap to 2.3 on average.
Eight other rural counties did not fare very well on the metrics either. Del Norte, Humboldt, Lake, Lassen, Modoc, Shasta, Siskiyou and Trinity counties launched their own nonprofit managed-care program in 2013, Howle stated, and it also has struggled to meet the state metrics, failing in 10.5 categories in 2015 and in six by 2018.
However, that county-run health care, known as Partnership HealthPlan of California, has performed much better than Anthem and Health & Wellness in ensuring Medi-Cal beneficiaries can easily access the specialty care they need, Howle wrote. In most cases, Partnership’s patients drive no more than 60 miles to see a specialist, exceeding that figure in only four categories in a January 2019 report.
In that report, Anthem and Health & Wellness reported asking Medi-Cal patients in Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn, Inyo, Mariposa, Mono, Nevada, Placer, Plumas, Sierra, Sutter, Tehama, Tuolomne and Yuba counties to drive 100 miles or more to see speciaists, Howle noted, a severe hardship for the state’s poorest residents.
300 miles to appointments
Anthem has scheduled these Medi-Cal patients with AIDS specialists, psychiatrists, pulmonologists and physical therapists more than 300 miles away, according to the auditor’s report, and Health & Wellness has directed patients to travel more than 300 miles to see dermatologists and 200 or more miles to see ear, nose and throat doctors; kidney specialists; and neurologists.
“Although it may be difficult for health plans to provide beneficiaries with close access to care when those beneficiaries reside in remote regions of the state, we would expect this difficult to equally affect all the health plans that serve rural counties,” Howle’s team wrote. “However...Partnership (Health) provided its beneficiaries in rural counties with access to most care within 60 miles.”
In a number of cases, Anthem and Health & Wellness could access specialists who are closer to the beneficiaries in need, but those specialists are not contracted with their managed care plans, and the insurers decided against sending patients out of network.
The Department of Health Care Services has the tools to monitor whether plans are meeting state requirements concerning access to care and the authority to force health plans to provide care closer to the patients, Howle explained, but it is not using either in a meaningful way. It has not required documentation needed to make these assessments or to determine whether a plan has exhausted all reasonable options to obtain closer providers, she reported.
“A beneficiary who has to travel hundreds of miles to receive medical care might be forced to miss an entire day of work and lose wages — a loss that might be critical considering that beneficiaries who qualify for Med-Cal while employed have limited incomes,” Howle wrote.
DHCS told Howle it was concerned that providers might demand “unreasonably high rates” if they knew DHCS would refuse to approve exemptions to how far patients could travel, but Howle’s team disagreed, saying the agency has not done the tracking it needs to monitor the availability of specialists in rural counties.
There are few agencies better suited to undertake this task, Howle said, and she urged DHCS to spell out the documentation it requires from health plans and to train its team to take on a watchdog role. The agency’s leaders said in their response that, while tracking the availability of specialists is within its purview, the Office of Statewide Health Planning and Development or the California Workforce Investment Board would be better suited to the task.
Support for counties urged
The auditor said that DHCS also must work to better support the 18 counties in monitoring the performance of Anthem and Health & Wellness and, if the counties desire, in undertaking a different model for delivering Medi-Cal services to their needy and vulnerable residents.
In 2012, after state leaders required the transition to managed-care plans, the eight northern rural counties worked with consultants or used their political clout to create their own nonprofit managed care plan, Howle wrote. Because their Partnership Health owes nothing to shareholders, she said, it can put more resources toward recruiting specialists to the service area and must report to a board of county leaders entrusted with upholding community standards.
All the rural counties could have created one of these county-operated health systems, Howle said, but not all the rural county leaders knew what it was or how to form one. A number of county leaders told Howle that they had wanted just such an organization but were told that they started too late in the game to get it done.
All of them have the opportunity now for a do-over, Howle said.
The contract with Health & Wellness expires in 2020 and the contract with Anthem in 2023, she explained. Howle recommended that DHCS begin now to do what it failed to do in the run-up to switch to managed care: Educate and guide leaders in the 18 rural counties that have a regional managed-care model about what they need to do to form a county-operated health system.
DHCS said in its response that it didn’t have the budget to do that in 2012-13 and that it still doesn’t have it now and does not plan to seek it. Instead, agency leaders urged the counties to request the funds to do so. The agency did detail a number of changes it plans to undertake from the auditor’s report, but the two parties remain at odds over issues such as the agency’s oversight and enforcement of regulations regarding access to care.