Medi-Cal is California's Medicaid program.
The initial shift of 178,000 children went off without much of a hitch, Toby Douglas, director of the Department of Health Care Services, said at a legislative oversight hearing in Sacramento.
"We finished the first phase of the transition, Phase 1A and ... all indications are, it was a successful transition," Douglas said. He said only 1% of those 178,000 children had to switch primary care providers and "99.9%" of them stayed with their same health plan. "And looking at all other indicators we have for dental and mental health and substance abuse disorder services, as well as grievances and appeals," he said, "the indications are, it was very successful."
Children's health advocates were slightly less enthusiastic, grading the state's transition effort with a C-minus.
In part, that low grade reflects a Bell curve of difficulty in this transition, said Kelly Hardy, executive director of Children Now. That is, the first parts are the easy parts, she said, and given the lower degree of initial difficulty, the expectations for the first phases of the transition need to be a little higher.
"There have been no widespread problems in the first phase, but major disruptions in care were not expected in this first phase," Hardy said.
Surveys have shown a lack of understanding about the Healthy Families transition among providers, assisters and beneficiaries, according to Victor Perez, an Anaheim pediatrician who is on the state governmental committee of the American Academy of Pediatrics, which conducted one of those surveys.
"A rough analysis from a survey of our membership showed that we're seeing an estimate of about 85,000 kids who could face problems with access and quality," Perez said. "This is really only a rough gauge of what pediatricians are seeing in the transition. I think the number's likely to be higher, as we expect the need will be greater as the transition expands into more challenging populations of children."
Later Phases Generate Greater Concern
The first phase of the transition (1A, which is now completed; 1B, which started on Mar. 1; and 1C, scheduled to begin Apr. 1) involve providers who already deliver services at lower Medi-Cal rates. Phase 2, which also is scheduled to start Apr. 1, likely will have little disruption for children and their parents, because they're Kaiser Permanente members.
Those earlier phases involve large segments of the Healthy Families population -- about 664,000 children. The third and fourth phases (beginning Aug. 1) involve a relatively smaller number of 193,000 children, but that group represents the biggest concern to advocates and health officials.
"What's going to happen to the 125,000 children in San Joaquin County whose providers don't take Medi-Cal and are scheduled to transition in August?" said Melina Yang, health advocate for Lao Family Community Empowerment in Stockton. "What is the state's plan to make sure those children don't lose coverage?"
Overall, Douglas said, relatively few families will need to switch primary care providers. The goal, he said, is to make sure all families retain coverage and access to care.
"Our goal is to bring all the providers over," Douglas said. He predicted more than 80% of the Healthy Families children will not need to switch providers. Douglas said children who will have to change providers still will get access to care.
"Our goal is to have continued access to providers," Douglas said. "We can't guarantee their continuation with the same provider. But our No. 1 goal here is that they have continued access to a provider, that they have continuity of care."
Evaluation Plan Lacking, Advocates Say
Given that the initial phase of implementation has such a low-hanging-fruit aspect to it, there should be fewer snags and omissions in evidence, Hardy said.
For one thing, she said, the state did not present a draft design of its Healthy Families evaluation plan to the Legislature. "Lack of an evaluation plan makes it difficult to define success in this transition," Hardy said, "and for us to evaluate how it's going."
Some deadlines have been missed, and several red flags have arisen so far, she said.
- "The state has not yet established electronic transfer of documents, and that deadline was Jan. 1," Hardy said.
- The deadline for an evaluation plan to be submitted to the Legislature was Jan. 31. DHCS did send a draft evaluation plan to CMS, and recently passed that document on to the Legislature.
- Children's advocates, in a Mar. 6 letter, said the DHCS plan failed to identify evaluation criteria or benchmarks, which was the whole point of developing a plan in the first place, the letter said. "We note that the draft evaluation design identifies seven specific goals/objectives -- but provides no information on how those goals will be measured," the advocates' letter said. "In other words, there is no way to judge whether the transition is successful based on this plan."
- The first monthly monitoring report was released by DHCS on Feb. 15. "It does provide useful information, but is inadequate in several ways," Hardy said. "It lacks overall context about how the children are being affected by the transition. It deals mostly with [Phase] 1A and not subsequent phases. And it lacks meaningful information about outcomes." For example, she said, a small number of Healthy Families children -- 1,847 -- were unable to keep their primary care provider. What's troubling, she said, is that there was no follow-up attempt to see if those beneficiaries were able to find new providers, and if they were able to obtain care. "We think this shows a lack of curiosity that is uncharacteristic of the department," Hardy said.
- At the February meeting of the Managed Risk Medical Insurance Board, which oversees the Healthy Families program, the number of families who requested terminations jumped by 40%, as did the number of dis-enrollments due to nonpayment. That may mean people are misinformed about Healthy Families, she said. They may have heard that Healthy Families is ending, but not that they will get the same coverage in Medi-Cal, she said.
"We're not sure what those numbers are about, but more investigation is needed," she said. "The real human impact of these issues is concerning."
According to Perez, the access issue is the big concern. If children have difficulty finding a new provider, particularly in rural and underserved areas, he said, that could be far more than an inconvenience.
"Delay in assessment or treatment in children can mean a great deal," Perez said, "with significantly worse outcomes. For a small child, a delay of a couple of months in interrupted service can be a really long time."
That's something Douglas said everyone is committed to preventing.
"With every transition we do, we take what we've learned and [apply] it to future ones," Douglas said. "It's our responsibility to do this in a phased-in way, so we do this in a way that we do not have major impacts on our beneficiaries."
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