COMMENTARIES ON HEALTH CARE : OPTIMA Can Help County in Harsh Medical Services Climate : There are 250,000 Medi-Cal recipients here, too many of whom cannot find a doctor for treatment.
What would you do if you, one of the lucky ones who actually has health care insurance, went to the emergency room only to find the door locked? Without a plan for delivering health care to the county’s uninsured and indigent population, such a situation is not far-fetched. The good news is that with a recent proposal for a county Organized Health Plan, the first of its size in the state, Orange County is displaying leadership where up to now there has been little.
We have a serious health care problem in Orange County, where there are 250,000 Medi-Cal recipients, too many of whom cannot find a doctor for treatment. Many if not most private physicians are loath to take these Medi-Cal patients because of the low reimbursement rate--averaging only 18 cents on the dollar.
Furthermore, health care issues pose a particular challenge in Orange County since there is no county-owned or -operated hospital, a condition that leaves Medi-Cal, indigent and uninsured patients who cannot find adequate health care no central place to go or call to find a physician for their primary care needs.
Due to the low reimbursement factor for Medi-Cal patients and the unduly burdensome paperwork associated with their treatment, physicians typically do not want to be on a referral list, so, these patients often end up in the emergency room which, by law, must treat them regardless of financial status and insurance eligibility. This, in turn, overburdens our already stressed emergency care system, and directly affects everyone of us because unless this problem is addressed, the time will come when no one is able to obtain emergency care.
Recognizing that the health care crisis is a significant public policy issue that needs to be addressed, the Board of Supervisors (at my initiation) established the Orange County Health Care Task Force in 1991 to bring together county government and the medical community. The efforts of the health care task force case management subcommittee, chaired by Dr. Richard F. Kammerman, immediate past president of the Orange County Medical Assn., have resulted in a unique proposal for a County Organized Health Care System.
The proposal, endorsed by the Board of Supervisors and the medical association, recommends that the organization and management of care for Medi-Cal patients be accomplished through an umbrella organization.
This coordinated effort, referred to as the Orange Prevention, Treatment, and Intervention Medical Assistance program, or OPTIMA, would receive all Medi-Cal funding from the state for eligible persons; arrange for the provision of all necessary medical services; and pay physicians for those services. Similar to privately run, managed-care HMOs, a patient would choose from among doctors who contract with this program.
The benefits of such a system are many. OPTIMA, under the leadership of a health authority separately established by the Board of Supervisors, will provide the flexibility to arrange the manner in which care is provided through local control of Medi-Cal. The system can be designed to meet the local needs of patients and providers while allowing the health authority to maintain fiscal control. In fact, if every primary care physician were willing to have just 6% of his or her practice consist of Medi-Cal patients through this proposed program, there would be more than enough access to primary and preventive care. This is also the first step to addressing the needs of the remaining uninsured, underinsured and medically indigent in Orange County.
The county anticipates receiving $567,000 for initial OPTIMA funding from the state, which has conditionally approved the County Organized Health System. Final determination should come this month.
Most significantly, OPTIMA will involve no cost to the county’s general fund. Rather, the proposed program will be fully funded by the state Department of Health Services and California Medical Assistance Commission.
In fact, there is room to generate significant savings--perhaps $175 million over the first five years. This savings will be realized through better management of Medi-Cal services and funding--which is the heart of OPTIMA.
By paying for and encouraging preventive care and early primary care, we have the ability to reduce the expensive emergency room services. Preventing an emergency visit when a patient’s condition is not really an emergency can save enough money to fund six to eight physician office visits.
With more than 250,000 Medi-Cal beneficiaries, Orange would be the largest county ever to implement an Organized Health System.
It has a unique opportunity to set a national precedent by turning the difficulty in obtaining medical care into an organized system that will improve the health of its Medi-Cal population and end the need for patients to resort to the emergency rooms as their only source of care.
