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Do Not Grant California's Request to Passively Enroll Dual Eligibles into Managed Care

Petition Summary: California currently has 1.9 million seniors and persons with disabilities who are enrolled in California’s Medicaid (Medi-Cal) program. The majority of Seniors and People with Disabilities, are eligible for Medi-Cal and Medicare.

The State of California has determined that the current financial and program structure for delivering health care Long Term Service and Support LTSS, that includes Home Community Based Services --- In Home Supportive Services to SPDs is fragmented. To address these issues, Governor Jerry Brown proposes as part of California’s 2012-13 budget, the (Managed) Care Coordination Initiative to integrate health care LTSS, Home Community Based Services --- In Home Supportive Services into Managed Care for all SPD’s who are dual eligible statewide beginning in January 2013.

Managed Care in California has been an unsuccessful health policy, as it has contributed to higher health care costs of about 25-33% higher over current state spending.  Managed Care will undermine patients' access to health care by: restricting patients' choice and access to physicians’ treatment and medication.  Under Managed Care SPD’s may lose or receive inadequate home care services and hours.  Finally they will no longer have the right to hire train set work schedules or fire their personal care attendance.

Action Petitioned For: We the undersigned are concerned citizens who urge our leaders to act now to Stop Mandatory Enrollment of People with Disabilities and Senior Citizens into Managed Care.

read petition letter ▾

We are concerned citizens affiliated with American Association for Retired Persons Advocacy Groups and People with Disabilities.   We are writing to you now because we can only express outrage at the damage that has been permitted to occur to Seniors and People Disabilities on the state's current Medi-Cal managed care program.  We the undersigned  2,030 petitioners http://www.thepetitionsite.com/518/711/384/senior-citizens-and-persons-with-disabilities-oppose-the-mandatory-enrollment-into-managed-care/ Stop Mandatory Enrollment of People with Disabilities and Senior Citizens into Managed Care  beseech you  do not grant California's request for waiver.  Do not approve passive enrollment of their Dual eligibles into managed care









California currently has 1.9 million seniors and persons with disabilities who are enrolled in California’s Medicaid (Medi-Cal) program. The majority of Seniors and People with Disabilities, are eligible for Medi-Cal and Medicare.
































The State of California has determined that the current financial and program structure for delivering health care Long Term Service and Support LTSS, that includes Home Community Based Services --- In Home Supportive Services to SPDs is fragmented. To address these issues, Governor Jerry Brown proposes as part of California’s 2012-13 budget, the (Managed) Care Coordination Initiative to integrate health care LTSS, Home Community Based Services In Home Supportive Services into Managed Care for all SPD’s who are dual eligible statewide beginning in January 2013.
































Managed Care in California has been an unsuccessful health policy, as it has contributed to higher health care costs of about 25-33% higher over current state spending.  Managed Care will undermine patients' access to health care by: restricting patients' choice and access to physicians’ treatment and medication.  Under Managed Care SPD’s may lose or receive inadequate home care services and hours.  Finally they will no longer have the right to hire train set work schedules or fire their personal care attendance.

















In 2010, the Legislature gave the Department of Health Care Services (DHCS) authority to undertake pilot projects to redesign care and treatment for vulnerable seniors enrolled in both Medicare and Medi-Cal, the “dual eligibles.” The pilot projects were supposed to take place in up to four counties, and seniors would be given the opportunity to opt out if they wanted to stay with their doctors. Before these pilot projects have even started, Governor Brown has proposed to rapidly expand them, to eight counties initially and statewide over the next two years. The plan for this transition is contained in a trailer bill to the State Budget, and a related proposal that has been submitted to the federal government. It has been titled the “Coordinated Care Initiative.”
















The State of California has received grant money from the Federal Government to develop the pilot project for managing its Medicare Medicaid population. In California Medicaid is called Medi-cal. The State initially put all its straight Medi-Cal population into managed care. Now the state wants to take those that have both Medicare and Medicaid (called Dual Eligibles or Duals) and put them into managed care too.

The (Duals) Plan that California came up fails the citizens in the following








1) This is no longer a “pilot project” or a “demonstration project.” Four counties authorized in existing law – Los Angeles, Orange, San Diego, and San Mateo – account for almost half of the state’s dual eligible population. With an additional four counties –Alameda, San Bernardino, Santa Clara, and Riverside – the projects will include almost 70% of the state’s dual eligible population. It simply includes too much of the target population.
















2) DHCS is proposing to shift 1.9 million and passively enroll seniors and people with disabilities into the dual eligibles project, and it is not clear how they’re going to do it. Under this program, dual eligibles will have the right to opt out and stay in traditional Medicare but not Medi-Cal with its interrelated services such as Long-term Care ---- Home Community Based Services. To exercise that right, they will have to be aware of what is happening and what paperwork they will need to complete. DHCS has not even developed a draft of the form that dual eligibles will use to select a plan or opt out. Preventing dual eligibles from exercising any choice will result in this medically vulnerable population losing access to longstanding relationships with their providers and proper access to Long-term Care Service ---- Home Community Based Services.
















3) The duals proposal must be seen in the context of other DHCS programs and proposals. Right now, the state is completing the transition of 400,000 Medi-Cal only seniors and persons with disabilities into Medi-Cal managed care.
















4) Will send billions of dollars into the pockets of certain HMO’s annually. These billions will be a loss to Medicaid Medi-Cal Medicare. The reason is that Dual Eligibles under fee-for-service will now generate $1,000 per month in pre-payment to the HMO by Medicare Medi-Cal. But in the coming years, if these people are put under “managed care” it will cost $1.9 million annually in unneeded payments out of the Medicaid Medi-Cal Medicare fund = a massive windfall for the HMO executives.
















According to The National Senior Citizens Law Center (NSCLC) Medi-Cal Managed Care participants are being seriously damaged by the states ill-chosen disorderly and poorly performing health plans with ratings on 7 of 8 Managed Care plans were 1 star (poor) out of 5 stars. http://www.nsclc.org/wp-content/uploads/2011/08/CA-Approved-Poor-Performing-Health-Plans-for-Care-of-Duals-5-2-12.pdf  "Assessing the Quality of California Dual Eligible Demonstration Health Plans"http://dualsdemoadvocacy.org/wp-content/uploads/2012/02/Plan-Ratings-Report-May-2012.pdf









In recent weeks that the Department of Health Care Services created a transition plan that relies on two firms that have drawn scrutiny from the U.S. Justice Department.   One in particular was the Senior Care Action Network, SCAN which fleeced the state of $330 Million in 2007.   State Senators Elaine Alquist, D-San Jose, and Alan Lowenthal, D-Long Beach, first requested that the Department of Health Care Services DHCS audit the SCAN Health Plan after receiving a report from a former SCAN employee about high profits.  Controller John Chiang urged the state’s Medi-Cal agency to recover the funds before routing former Adult Day Health Care participants into the SCAN Health Plan. http://californiawatch.org/dailyreport/health-plan-fleeced-state-stands-grow-1212  









Medi-Cal auditors determined that in 2007, SCAN earned $100 million from the federal Medicare program and $100 million from the Medi-Cal program to manage care for 6,430 seniors. The cost for caring for the seniors was about $103 million, leaving the firm with $96 million in profits that year. Medi-Cal auditors estimated that SCAN earned an 83 percent profit off the state-administered funds.

















Controller Chiang reviewed the audit results and wrote a letter last year to SCAN Health Plan chief executive David Schmidt, decrying the plan’s failure “to meet its contractually-obligated reporting requirements” that would have allowed DHCS to spot the overpayment's earlier.  Still, Chiang wrote that he is “deeply concerned” that the department “conducted no analysis of SCAN’s effectiveness before renewing a $1.44 billion contract for five years.”








In the audit report, the department said it took action to address the issues by ensuring that SCAN submits certifiable financial reports on its Medi-Cal program. Also, the department cut its payments to the health plan by 70 percent from the 2008 level, the audit shows.  But DHCS did not take steps to recover any of the overpayment's made to SCAN. However, DHCS is turning to the SCAN Health Plan and the poor performing health plans in its transition strategy  of dual eligible's.









5) When Seniors and People with Disabilities need to see their specialists that they’ve seen for years, they have to make an appointment with a “gate-keeper” doctor who is unfamiliar with their conditions and beg them for a referral which they may or may not give, depending on the “gate-keeper” doctor’s opinion and the plans’ restrictions.   What is even worse is that already authorized life preserving treatments are interrupted or just plain denied. From June to December 2011 Managed Care only approved 15% of requests to these people who are replete with complex medical conditions.









6) It will “cannibalize” important other Medicare Medi-Cal related programs such as Long Term Care Service LTCS--- Home Community Based Services HCBS. Approximately 70-85% of the statewide Home Community Based Service caseload are dual beneficiaries and, could therefore, be shifted away from the traditional HCBS program and into the dual integration projects.








Established in 1973 under Governor Ronald Regan, In-Home Supportive Services a HCBS is a statewide public program providing in-home personal assistance services to individuals who are blind, disabled, and/or elderly.
















These include services such as:

























        • bathing;



































        • dressing;



































        • transferring;



































        • domestic assistance such as;



































        • meal preparation,



































        • shopping,



































        • heavy house cleaning; and



































        • protective supervision. 






















The prospect of In-Home Supportive Services IHSS being included in this managed health care is equally terrifying. The IHSS program in California is a beacon to other states of cost-effectiveness while giving dignity and humanity to seniors and people disabilities to live productive lives when they can and lives of dignity when disability and advanced age prevents it.
















The In-Home Supportive Services (IHSS) program, along with residential care and other programs are seen as important resources in reducing nursing home utilization in California (CA Assembly Budget Subcommittee No.1, 2004). IHSS is California's main program of in-home and community-based long-term care services.  Currently it serves 320,000 recipients monthly. This program is financed through a combination of federal funds through Medi-Cal, state and county funds.









California's In-Home Supportive Services (IHSS) program allows participants who can choose to hire and fire our own workers, rather than receiving case managed services through an agency.  As employers, they can direct their care and be more responsible for its quality. A study funded by the Department of Health and Human Services compared client and worker outcomes for those participating in IHSS's independent provider program with those receiving case-managed services from a county agency (Doty et al., 1999).









The studies principal finding is that clients in the consumer-directed model had more desirable outcomes than those receiving professionally managed services within three broadly defined areas:



















        1. satisfaction with services,























        1. empowerment,























        1. quality of life.
















The theory that private agencies assigning IHSS contract workers will find opportunities to consolidate services and discover new efficiencies is not true. While there is no fact based evidence for such consolidation and efficiencies could not be found with the existing public administration.   
















As a test case in Tulare County demonstrated, privatizing these services is not the best way forward. In 1992, the California Department of Social Services began a test project to see if IHSS could be effectively delivered via contract mode and potentially save the state resources.  The results of the project found that the private contractor cut hours of service for recipients and pushed family and relatives to administer care the contractor refused to provide, in some cases leaving the needy individual to just go without.   Additionally, administrative costs increased dramatically in Tulare County under the private contract system.   With hourly program costs 60% higher than the statewide average, managed care in Tulare was less efficient, less effective in serving the neediest population, and far more expensive than the state and its comparison counties.   The project ultimately showed contract mode to be more costly to the state and less effective at delivering better quality of care.   Using “contract mode” to administer these services has been shown to be ineffective. Not only does it present a number of problems for the care recipients, but this mode of administration is less efficient and less effective than individual provider mode.  

















Further, “contract mode” has already been tested and shown to be ineffective and inefficient.  In 1992, the California Department of Social Services began a test project to see if IHSS could be effectively delivered via contract mode and potentially save the state resources.  The results of the project found that the private contractor cut hours of service for recipients and pushed family and relatives to administer care the contractor refused to provide, in some cases leaving the needy individual to just go without.   Additionally, administrative costs increased dramatically in Tulare County under the private contract system.   

















“With hourly program costs 60% higher than the statewide average, managed care in Tulare was less efficient, less effective in serving the neediest population, and far more expensive than the state and its comparison counties.”  








 








The project ultimately showed contract mode to be more costly to the state and less effective at delivering better quality of care.  








 








Factor in the profit expected by the private administrator and it is difficult to see how IHSS could possibly be administered for less cost and in a more humane manner.  Privatization of In Home Supportive Services: Not a realistic way to save state resources or care for the needy.  There is no reason why such consolidation and efficiencies couldn’t be found with the existing public administration.








 








1.     [PDF] Page 1 Page 2 TABLE OF CONTENTS EXECUTIVE SUMMARY ... www.ihsscoalition.org/documents/ihss1995.pdf demonstration project to test whether all eligible IHSS clients in a county could ... Tulare County's 1994 IHSS program served less needy clients, depended more ...








2.     IHSS | In-Home Supportive Services Coalition www.ihsscoalition.org/Cached - SimilarYou +1'd this publicly. Undo  The IHSS Coalition is a group comprised of stakeholders in the California ... AT REINVENTING IHSS, THE TULARE COUNTY  DEMONSTRATION PROJECT ...








3.     [PDF] Implications of the Tulare County Demonstration Project www.csus.edu/isr/reports/tulare1996.pdf Implications of the Tulare County IHSS Demonstration Project 3. Tulare's service delivery was concentrated not only on the elderly, but on the most functional ...
















Tulare county IHSS demonstration project: an evaluation of managed care. Institute for Social Research California State University, Sacramento, Sacramento, ...
















7) It will promote abuse of the disabled and elderly for financial gain. The following is an excerpt of a letter Katie Murphy, Managing Attorney of Neighborhood Legal Services of LA County written to the legislators RE: The Patient/Consumer Perspective: Current SPD Implementation Barriers to Good Health Outcomes 
1.  No meaningful access to the Exemption process, leaving patients with a remedy to stay with essential providers on paper, but not in reality.









2.  No meaningful implementation of the Continuity of Care procedures, both to retain existing doctors and honor existing treatment authorizations,  prescriptions, and surgeries, leaving patients who are defaulted or chose a plan with a remedy for continuity in theory, but not in practice; and 








3.  Severely medically needy patients with delicate treatment plans having to start all over within a plan once enrolled, losing valuable time and going without care; themselves without the health literacy to chart and case managed their own medical treatment plans, or even communicate their histories effectively, unable to explain why they had step therapies, why only certain drugs work, or what is planned next, and without doctors who believe them even if they can explain; and without a plan physician entrusted with medical history, records, and other data; and without a responsible physician charged with the duty to smoothly transition the care, not just the patient.

















The three example above will befall dual eligible SPD.








Here is just one example from a petitioner.

HOW MANAGED CARE TREATS A CARDIAC PATIENT LIKE A "CHECKER ON A CHECKERBOARD" ---








(1) a patient age 72 presented to the Emergency Room of Hospital A with chest pain.
(2) Hospital A is FULLY EQUIPPED to treat cardiac disease there is stress testing - cath lab - angioplasty - and heart surgery
(3) the plan however has a CHEAPER contract with Hospital B 10 miles away from Hospital A
(4) But Hospital B has NO STRESS TESTING -NO CATH LAB - NO ANGIOPLASTY- NO CARDIAC SURGERY
(5) If the patient was to have further chest pain at Hospital B it could develop into a Life and Death Emergency to get out of Hospital B back to a Hospital like A because then the plan would be obligated to move the patient
(6) without explaining the deficiencies of Hospital B to the patient (who is Spanish speaking) the patient was simply placed on an ambulance and delivered into Hospital B
(7) Had the patient possessed the original Medicare and Medi-Cal it would have cost nothing to the patient to be treated at Hospital A.
(8) it is only because "managed care" now "controls the patient costs" that they are willing to jeopardize the patient's life (unbeknown to the patient herself that she is being maneuvered in such a fashion)





Secretary Sebelius Preserve the financial integrity of our Medicare Medicaid Medi-Cal long with Home Community Based Services programs and show their worth before shutting them down by removing t our disabled and elderly en masse















Do not grant California's request for waiver.  Do not approve passive enrollment of their Dual eligibles into managed care





Creator of the On-line Petition Audrey Harthorn said, “Access to health care is an individual and civil right.”  “The State does not have the right to decide how or with whom I receive health care from.” 









Petitioner # 2 Nancy Becker Kennedy, CA “Seniors and People with Disabilities are too fragile a population to rush into a managed care system that is already endangering the people rushed into Medi-Cal managed care last year. Until the state takes responsibility and gets people and Medi-Cal managed care their surgeries dialysis transplants etc., they have absolutely no business getting more people into a dangerously chaotic system. The negligence and harm being done to people on Medi-Cal managed care now is unconscionable!. Some people with disabilities have had decades long relationships with their disability specialists. It will be like endangering to break up these relationships in some instances. To deal of fragile populations in this way is something history will rebuke. To hurt our most vulnerable people because of a budget crisis is immoral. The right thing to do would be truthful to the public that lives are being endangered and that's a modest revenues must be increased to live in a civilized state.”








Petitioner # 107 Solomon Rabinowitz MD, CA stated “The forced placement of medi-medi patients into capitated care is being described by wall street as "multi-billion dollar opportunities for growth" for companies like Healthnet and Molina”  “But from whom are these billions being taken? Answer : The elderly and disabled each dollar of value (equity) that is being doled out by Washington and Sacramento to these for-profit HMO companies Is the same dollar being withheld from-- the (needed) medical care of the elderly and disabled The worst part of it -- the patient is "opted-in by default" [ on 1-1-2013 with a six month lock-in before there is another chance to opt out ] the least savvy -- and most vulnerable -- are thus sacrificed to wall street's altar of profit (Until they can wake up and opt out ) That is why the default needs to be " opted-out " until the patient requests to be "opted –in."








Petitioner  # 1,981 Mr. Lynn Murray, CA This effort to move seniors and persons with a disability smacks of discrimination. Is the same done for persons with cancer, diabetes, other medical conditions? No. What - therefore - is the rationale supporting such legislation? There is none short of "culling the herd." Last time I heard of that being done was WWII. Enough said.








Petitioner  # 1,999 Ana Solis, CA HOW MANAGED CARE TREATS A CARDIAC PATIENT LIKE A "CHECKER ON A CHECKERBOARD" --- (1) a patient age 72 presented to the Emergency Room of Hospital A with chest pain. (2) Hospital A is FULLY EQUIPPED to treat cardiac disease i.e there is stress testing - cath lab - angioplasty - and heart surgery (3) the plan however has a CHEAPER contract with Hospital B 10 miles away from Hospital A (4) But Hospital B has NO STRESS TESTING - NO CATH LAB - NO ANGIOPLASTY- NO CARDIAC SURGERY (5) If the patient was to have further chest pain at Hospital B it could develop into a Life and Death Emergency to get out of Hospital B back to a Hospital like A because then the plan would be obligated to move the patient (6) without explaining the deficiencies of Hospital B to the patient (who is Spanish-speaking) the patient was simply placed on an ambulance and delivered into Hospital B (7) Had the patient possessed original Medicare Medi-Cal it would have cost nothing to the patient to be treated at Hospital A. (8) it is only because "managed care" now "controls the patient costs" that they are willing to jeopardize the patient's life (unbeknown to the patient herself that she is being maneuvered in such a fashion) (9) THIS COMPLAINT WILL BE FORWARDED TO KATHLEEN SEBELIUS DIRECTOR HHS; AND TOBY DOUGLAS DIRECTOR MEDI-CAL








Petitioner  # 1,948 Dr. Misha Lanzat, CA This population consists of most vulnerable seniors and disabled. Managed care groups are simply not set up to provide those patients the personalized care they need and deserve. They do not have specialists available at the time of need. There is absolutely no financial savings (look at CBO report and they studied Medicare HMO's for 20 years!!!). CMS has issued a waiver to essentially remove the right of choice from this group of Americans; predominantly Hispanic, Black, Disabled and Asian.








Petitioner  # 1,802 Ms. Angela Gardner, CA Dual eligibles long-term services and supports should not be privatized to the for profit managed care companies. Many of these people will lose access to quality care and long-term care services they need. Managed care is not legally mandated to offer community based long-term care and other support services because the Federal Center for Medicare and Medicaid services only funds 33% of community based services and the state has to cover the rest. Managed care will get funding at 67% from Centers for Medicare and Medicaid Services for institutional care (nursing homes). There is no incentive for managed care to offer these services. They can do what they want with no oversight from the state. This proposal does not protect dual eligibles. The political idol worship of the corporations and handing over public tax payer money to them must end now!








Petitioner  # 1,784 Dr. Ganesha Kandavel, CA Mandatory enrollment into any health plan without proper consent and information is a predatory practice.








Petitioner  # 1,770 Ms. Olympia Santana, CA I am myself dealing at this moment with the stupidity of "Required Managed Care" and trying to get back to my regular Medi-Cal. It is so unnerving and such a BAD idea/plan/"solution" to this system that, as bad as it can be for many, it works BETTER for many of us who need a specialized type of care! Is so frustrating to deal with the Opting-Out back and forth, ad now am having to request a State Hearing so I can be left-out of the HMO management. THINK about many of us whom are not able to PAY a private care system to help us with our health and physical as mental wellness. I need a very specific specialist and care that to have my health being shuffled around would seriously attempt against my life. What are these politicians trying to do??!! Kill us??!! PLEASE STOP THIS INSANITY! Thank you.
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