Health Disparities

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The CHOICE Study: Consumer Health Care Options: Investigating Cal MediConnect Enrollment

Why did three in five of the poorest, sickest residents in Los Angeles County reject a managed health care program meant to improve their access to health services? The CHOICE Study was a two-year project that attempted to answer this question by interviewing eligible enrollees about their decision-making processes.
The program  Cal MediConnect  integrates financing and delivery of medical, mental health and other health care services for 415,000 medically frail elderly or severely disabled young Californians who qualify for both Medicare and Medi-Cal benefits.  Seven California counties participated in the pilot program with the aim of enrolling up to 1.1 million people. 
Yet to date enrollment levels remain low, especially in Los Angeles County. Through 53 in-depth, one-on-one interviews and six focus groups (36 participants total) the CHOICE Study documented knowledge, perceptions and concerns of those eligible for the program.
The study was conducted by the UCLA Center for Health Policy Research in partnership with the Westside Center for Independent Living and a Community Advisory Group of five consumers and five stakeholders.

Read the CHOICE Study:
Individual case studies: The CHOICE Study (2015-2017):
These individual-level case studies illustrate the decision-making experiences of some of the dually-eligible health care consumers who participated in The CHOICE Study.

Ashley first heard about Cal MediConnect (CMC) from a representative from the Center for Health Care Rights who gave a talk about CMC that was specifically tailored for individuals with neurologic disorders. Ashley found that the information presented was not only comprehensive but also easy to understand. By the end of the presentation, Ashley was fully aware of her enrollment options and knew that she needed to make a decision. After seeking additional advice from several sources, Ashley came to the conclusion that CMC was too restrictive and would likely inhibit her ability to exercise choice.

Jose enrolled in a Cal MediConnect plan after reading the Spanish-language information contained in the blue Cal MediConnect mailers. He said he was pleased with his decision and felt well informed because of the CMC mailers and his consultation with a local insurance provider. Jose's transition to the new program also went smoothly and he was happy to be offered new services and benefits, such as transportation and no-cost medications. He was also able to remain with his current physicians, which he appreciated. Jose's main priority was maintaining access to his primary care provider.

Maria understands and speaks a little English but prefers communicating in Spanish. Language becomes a barrier when Maria has questions or concerns about her health care, making her feel helpless. Maria seemed at first to be unaware of the Cal MediConnect options available to her; she may have either ignored or dismissed the blue envelope notifications, not understanding that they required action. However, shortly after Maria received the CMC notices, a woman called and came to her home to offer her a CMC plan. Maria understood that she was required to enroll in a CMC plan, and she agreed to switch to the representative's plan when she learned that she would receive more benefits and save money. 

Martha survived a heart transplant and currently relies on her primary care provider (PCP) of 10 years and a network of specialists who help her manage multiple chronic health conditions. When she first learned about Cal MediConnect, Martha quickly decided that she wanted to opt out and retain her Medicare benefits. However, she still had to select a managed care plan for her Medi-Cal benefits. While she tried to review the enrollment information on her own, Martha found the materials long and the process confusing. After consulting with her PCP, Martha chose the managed care plan that he recommended.

Peter does not involve friends or family in his health care decision-making. Instead, he relies mainly on his primary care doctor for referrals to specialists and for health-care-related decisions. Prior to enrolling in CMC, Peter was unaware of his options and the extra benefits that many of the CMC plans provided. He believed his only option was to join a CMC plan and be compliant with Obamacare. Peter thought joining CMC was mandatory; he was not aware that he could have kept his original Medicare Advantage plan or switched back to original Medicare.
Composite case studies: The CHOICE Study (2015-2017):
These composite case studies highlight the experiences of certain subgroups of dually-eligible health care consumers who participated in The CHOICE Study.

Passive enrollment into Cal MediConnect (CMC) occurred if a dual eligible consumer did not make the choice; he or she was then automatically enrolled into a CMC plan. CMC's passive enrollment process disrupted existing care for most of the dual-eligible consumers in this case study. Loss of long-established relationships with primary care doctors and specialists was the primary factor that guided their decisions to dis-enroll. Many had been with their doctors for several years, and when they discovered that their providers were not part of CMC, they immediately knew that they would dis-enroll from the plan. Continuity of care was their highest priority.

In Los Angeles County, Latino dual-eligible health care consumers are more likely than most other racial/ethnic groups to be enrolled in the Cal MediConnect (CMC) program. This case study focuses on 10 Latino consumers who participated in the CHOICE Study. Spanish is the predominant language of 5 of the consumers in this group, all of whom were enrolled in CMC. These Spanish-speaking Latinos were not aware of all the health plan options available to them. Many did not have accurate or complete information about the CMC program; some misinterpreted the information they did have. Conversely, the English-speaking Latinos in this case study were generally more informed about the health plan options available to them.

About 53% of the consumers who opted out of CMC in Los Angeles County were between the ages of 21 and 64, a group designated as "younger" for the purpose of the CHOICE Study. Los Angeles County has the highest rate of younger consumers who opted out when compared with the remaining six demonstration counties that have opt out-rates ranging from 10% to 45%.  This case study examines and compares the decision-making experiences of these consumers in the context of three specific themes: knowledge of health care options, perception of choice, and disruption of existing care.

Funding source: Support for this research was provided by the Robert Wood Johnson Foundation (grant #73052). The views expressed here do not necessarily reflect the views of the Foundation.

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