​Kate McBride is a graduate student researcher at the Center and lead author of a new policy brief on medically fragile Angelenos who rejected a new managed care health plan, Cal MediConnect. In this brief interview, McBride discusses the high rate of opt-outs for the program, the tug between care and cost, and how Cal MediConnect can keep people in their existing care networks.

Q: Why did these consumers reject the program in such a big way? Just 19 percent stayed enrolled, and 58 percent went through the trouble of opting out.

​Being able to maintain continuity of care was the highest priority for dual-eligible consumers. Participants in our study who anticipated that enrollment in Cal MediConnect (CMC) would lead to a disruption in their care, either through the loss of their doctor or preferred health services, were more likely to opt out or dis-enroll from the program.

These participants emphasized the importance of keeping their relationships with their current health care providers (primary care and/or specialists) and services or products (pharmacies, durable medical equipment suppliers). Although all dual-eligible beneficiaries enrolled in CMC can continue to see their present doctors and receive existing services for up to a year in order to ease the transition, many were either unaware of this option, or unwilling to undergo the process of choosing a new provider within the CMC network, but who would be unfamiliar with their complex medical history.

CMC's status as a managed care plan was also seen as a disadvantage among participants who believed that managed care plans typically provide fewer choices. These individuals voiced concerns that the network of doctors and specialists in managed care plans is limited compared to FFS Medicare, and that managed care plans impose more restrictions on services and benefits.

Q: The program was started to address gaps in health care services. Does the program actually provide better coverage for this group of vulnerable consumers?

​Dual-eligible consumers are faced with the challenge of navigating two different health delivery programs that have different requirements and provide different health care services, which contributes to the existing fragmented and uncoordinated care for this population. The purpose of integrating Medicare and Medicaid for dual-eligible consumers was to create a more unified system of accessing and utilizing health care benefits and services, with the goal of improving quality of care and reducing costs. CMC is responsible for delivery and coordination of medical, behavioral health, long-term services and supports. All services are administered through CMC health plans, which offer supplemental benefits, such as care coordination, medical and non-medical transportation, and vision and dental benefits.

While consumers in our study agreed there were numerous advantages to having extra benefits and services with Cal MediConnect, including lower out-of-pocket costs, access to specialists and specialty services became more difficult to obtain under their new CMC plans due to authorization requirements.

Ultimately, the decision to opt out or dis-enroll involved weighing the extra benefits of CMC ― such as transportation, dental, and vision services ― versus the loss of primary care doctors and specialists. For these participants, remaining with their trusted doctors who had extensive knowledge of their medical history was the most important factor in their decision-making process, even though the decision left them with more limited services.

Q: Dual-eligible consumers are very concerned about losing their trusted network of providers. What could Cal MediConnect and other similar programs do better to address this?

​Several states are currently testing new models of care delivery for dual-eligible beneficiaries to better manage high-risk, high-cost patients.

For example, Washington state is currently testing an integrative managed fee-for- service (MFFS) model for dual-eligibles, known as the Washington Health Homes Program. In contrast to the CMC model in California, Washington state is building upon its existing Medicaid Health Homes to target dual-eligible beneficiaries with chronic health conditions. Beneficiaries are free to choose whether to receive these new services, and continue to have access to the same Medicare and Medicaid services and benefits, resulting in no disruption in care. The program has been extremely successful to date, and has reduced inpatient hospital admission, emergency room visits, inpatient psychiatric admissions, and the need for nursing home admissions.

Maintaining continuity of care and avoiding disruption to ongoing services were the main priorities for virtually all consumers in our study. Rather than disrupt the existing care networks of vulnerable health care consumers, California and other states with similar programs should consider implementing a coordinating agency to streamline existing health care services for consumers, or develop other management strategies to coordinate Medicare and Medicaid benefits, while offering supplemental services and referrals to community supports and services.