By Bernard J. Wolfson
Theresa Grant, a resident of Culver City, has endured debilitating pain for the last year from a mysterious bulge protruding from her lower rib cage.
She takes multiple painkillers every day. And the cause of her agony remains undiagnosed because, despite her tenacious efforts, she hasn’t been able to get a referral to a suitable doctor.
Grant, 63, is in Medi-Cal, California’s version of Medicaid, the program for people with low incomes. She is enrolled in L.A. Care, one of two managed-care Medi-Cal health plans in Los Angeles County and the largest one in the state, with 2.4 million members.
L.A. Care and many of the other 24 Medi-Cal managed-care plans across the state outsource responsibility for their patients to independent physician associations and in many cases to 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 many instances and is common in managed-care Medi-Cal, which covers over 80% of the program’s 14 million enrollees.
But advocates, state regulators and even some health plan executives agree it is confusing and creates obstacles for many Medi-Cal patients, who tend to be poor and from minority communities, often face language barriers and have high rates of chronic illness.
“You’re on Medi-Cal, your last 10 bucks is for the bus, and when you need something, you don’t know who to ask,” said Alex Briscoe, head of the California Children’s Trust and former director of the Alameda County Health Care Services Agency. “The complexity is like salt in the wounds of people trying to navigate the healthcare 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 rules 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 a record $124 billion this fiscal year, medical providers frequently complain that its payments are insufficient — and critics say each layer of administration diminishes the pool of dollars available for healthcare.
The worst part is the physical toll such a confounding system can 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 just to shop or do her laundry.
“I was muscular. I always used my body. Now, I can’t even recognize myself,” she said.
Although L.A. Care is ultimately responsible for Grant, it delegates her care to a physician 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 ultimately to the Department of Managed Health Care, one of the state’s two health insurance regulators, seeking authorization to see a thoracic surgeon about her rib cage.
But the doctors to whom she’s been referred were either the wrong type, had already unsuccessfully treated her or had been sued repeatedly for malpractice. Some, she said, were no longer in practice or had moved out of state.
L.A. Care said in a statement that it “takes seriously all member concerns that are brought to the health plan’s attention” and is “troubled to learn when any resident in Los Angeles County is not getting needed medical care.”
L.A. Care, which relies on delegation more than any other Medi-Cal plan in 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 — as well as about 55 physician networks. Community health clinics and the county’s public health system are also 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.
Typically, the health plans pay their subcontractors a fixed monthly fee per enrollee. The plans take a percentage of the money they receive from the state to cover the oversight of their subcontractors and are generally off the hook financially for care of those patients.
“It’s a reliable portion of our bottom line and gives some stability to our finances,” said John Baackes, L.A. Care’s chief executive.
Health plan executives say subcontracting gives patients more choices.
In Los Angeles County, for example, the 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 actually choose from six plans.
Skeptics say the idea of broader choice is illusory because whichever plan patients choose, they end up with specific physician networks and are usually restricted to their providers.
“They operate as these mini-plans within a plan, and 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, and others, like Grant, may not want to change.
“I am reluctant to join another IPA because I’d lose my primary care doctor, and I’d have to start from scratch,” she said.
Wolfson writes for Kaiser Health News.