Theresa Grant, a resident of Culver City, California, has endured debilitating pain within the last year from a mysterious bulge protruding from her lower rib cage.
She takes multiple painkillers every single day. And also the reason for her agony remains undiagnosed because, despite her tenacious efforts, she was not capable of getting a referral to a suitable doctor. Grant, 63, is within Medi-Cal, California's version of Medicaid, the program for those who have low incomes. She is enrolled in L.A. Care, one of two managed-care Medi-Cal health plans in Los Angeles County and also the largest one in their state, with 2.4 million members.
L.A. Care and many from the other 24 Medi-Cal managed-care plans over the state outsource responsibility for their patients to independent physician associations and in some cases with other health plans. The subcontracted plans also delegate to IPAs, physician networks that in turn often hire outside management firms to handle medical authorizations and claims.
This multilayered, delegated care works in most cases and it is common in managed-care Medi-Cal, which covers over 80% from the program's 14 million enrollees. But advocates, state regulators and even some health plan executives agree it's confusing and creates obstacles for a lot of Medi-Cal patients, who are usually poor and from minority communities, often face language barriers and also have high rates of chronic illness.
“You're on Medi-Cal, your last 10 dollars is perfect for the bus, and when you'll need something, you don't know who to inquire about,” said Alex Briscoe, head of the California Children's Trust and former director of the Alameda County Healthcare Services Agency. “The complexity is much like salt in the wounds of people trying to navigate the health care system.”
Moreover, health plans often exercise weak oversight of subcontractors, allowing some to get away with inferior care or unwarranted denials. The state has promised to tighten the guidelines for Medi-Cal plans and providers in new managed-care contracts scheduled to take effect in 2024.
Although spending on Medi-Cal is projected to reach an archive $124 billion this fiscal year, medical providers frequently complain that it is payments are insufficient – and critics say each layer of administration diminishes the pool of dollars available for health care.
The worst part is the physical toll such a confounding system may take on enrollees. Grant, who describes herself as a person of color, spends most of her time sequestered at home and has to gird herself with extra pain medication simply to shop or do her laundry. “I was muscular. I usually used my body. Now, I can not even recognize myself,” she said.
Although L.A. Care is ultimately responsible for Grant, it delegates her choose to a health care provider network called Prospect Medical Group. Prospect, in turn, contracts with a medical management company called MedPoint Management.
Grant said she's gone from Prospect to MedPoint to L.A. Care and eventually towards the Department of Managed Health Care, one of the state's two medical health insurance regulators, seeking authorization to see a thoracic surgeon about her rib cage. However the doctors with whom she's been referred were either the incorrect type, had already unsuccessfully treated her or have been sued repeatedly for malpractice. Some, she said, weren't any longer in practice or had moved out of state.
L.A. Care said in a statement it “takes seriously all member concerns that are delivered to the plan's attention” and it is “troubled to understand when any resident in Los Angeles County is not getting needed health care.”
L.A. Care, which depends on delegation more than every other Medi-Cal plan within the state, has about 58 subcontractors under its umbrella. That group includes three health plans – Kaiser Permanente, Anthem Blue Cross and Blue Shield of California – along with 55 physician networks. Community health clinics and the county's public health system will also be in L.A. Care's network.
CalOptima, which runs Medi-Cal for Orange County's 860,000 beneficiaries, subcontracts with Kaiser Permanente and 11 physician associations, said its chief operating officer, Yunkyung Kim.
The Alameda Alliance for Health, one of two Medi-Cal health plans in Alameda County, delegates full responsibility for around 43,000 of their 300,000 enrollees to Kaiser Permanente, said Scott Coffin, its CEO. It also subcontracts varying degrees of responsibility to some chain of community health clinics, a pediatric medical group and also the county's public health system, he said.
Typically, the health plans pay their subcontractors a fixed monthly fee per enrollee. The plans have a number of the money they receive in the state to cover the oversight of the subcontractors and are generally free financially for care of those patients.
“It's a reliable portion of our main point here and provides some stability to our finances,” said John Baackes, L.A. Care's CEO.
Health plan executives say subcontracting gives patients more choices.
In Los Angeles County, for instance, their state contracts with two health plans: L.A. Care and Health Net. Because L.A. Care subcontracts with three other health plans and Health Net with one – Molina Healthcare – Medi-Cal enrollees can in fact select from six plans.
Skeptics say the idea of broader choice is illusory because whichever plan patients choose, they end up getting specific physician networks and therefore are usually limited to their providers.
“They operate as these mini-plans within a plan, as well as their networks are very narrow,” said Abigail Coursolle, a senior attorney at the National Health Law Program in Los Angeles.
Medi-Cal enrollees can change providers every month if they wish, Baackes said. But some might not know they have that right, yet others, like Grant, might not want to change. “I am unwilling to join another IPA because I'd lose my primary care doctor, and I'd have to start from scratch,” she said.
Switching providers every month is not conducive to get affordable health, said William Barcellona, executive v . p . of government affairs at America's Physician Groups, which represents IPAs and medical groups.
When people first enter managed care, they should be assessed for chronic illnesses and mental health insurance and then because of the care they require, he explained. “You can't do this when somebody can simply move about the machine every Thirty days.”
When delegation is done right, it's really a more effective way of delivering care, especially in large, populous counties with diverse communities.
“It's like a contractor on a house. Would it seem sensible for the contractor to be doing the wiring and also the plumbing and also the drywall himself?” asked Jennifer Kent, who ran the Department of Health Care Services, which administers Medi-Cal, from 2022 to 2022. “He could, and when he's good at it, great. But he's most likely not as efficient as if he's overseeing the drywall guy and also the plumber and he's monitoring the quality.”
But it becomes a problem once the health plans' oversight of the medical groups is lacking, Kent said. And that's a big problem in Medi-Cal, agree advocates, patients assuring health officials.
The new Medi-Cal contracts will “significantly strengthen and clarify requirements and expectations” around the managed-care plans with regard to oversight and compliance of their subcontractors, said Anthony Cava, a spokesperson for that Department of Health Care Services.
The contracts will specify which requirements to incorporate in subcontractor agreements and designate certain functions that the managed-care plans may not delegate, Cava said. The contracts will also require intends to report on timely access and quality of care for all of their subcontractors.
Currently, plans report data only within the aggregate, which hides wide variations in performance and enables subpar performers to evade detection. This means the health plan quality scores authored by their state don't always reflect the real-life experiences of patients. Health plans have a hard time getting reports on patient visits from their physician groups, which in turn usually have difficulty getting it from the doctors within their networks.
To be sure, some plans have previously made efforts to determine the performance of the subcontractors.
The Alameda Alliance created a committee to monitor its subcontractors, Coffin said. It oversees annual audits and posts “dashboards” to track subcontractors' performance.
Baackes asserted when he first took the helm at L.A. Care in 2022, its physician groups offered proper care of inconsistent quality. He implemented a report card for all subcontractors, and since then, the laggards have upped their game, he explained.
But Baackes isn't a fan of the sprawling delegated system he inherited. The executive layers make it expensive, and every one “adds an opportunity for anyone to drop the ball,” he said.
Grant and other enrollees who feel ill-served by Medi-Cal would likely agree.
Last week, Grant finally saw a UCLA surgeon she thought may help her. The surgeon, who focused on cardiovascular issues, didn't have a solution for her ribcage problem but found a spot on her lung. Once more, Grant remained to her own devices and had to create several telephone calls to arrange for any CT scan from the growth.
She praised her doctor and the assistant as “caring and good people” who've tried to help her. But she gets betrayed by the system.
“It's like they purposefully confuse you so they possess the upper hand,” she said. “That's the way i view it. How could I not?”
This story was made by KHN, which publishes California Healthline, an editorially independent service from the California Healthcare Foundation.
Bernard J. Wolfson:
bwolfson@kff.org,
@bjwolfson
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