Managed-Care Program in O.C. Gets Bad Marks

Orange County’s managed-care program for poor patients--only 4 months old--is under attack by community doctors and other long-time Medi-Cal providers who accuse program organizers of greed, inefficiency and a callous attitude toward patients.

Their anger boiled over Thursday at a hastily organized meeting at a Garden Grove church. Providers shouted down two representatives from the county’s Cal-OPTIMA program and chastised them for implementing the system without consulting those who have loyally treated Medi-Cal patients for years.

“Cal-OPTIMA came in and has put a tremendous burden on our practices--increasing paperwork, causing us to make phone calls constantly,” said Dr. Burton Lutsky, a family practitioner, one of about 50 providers at the meeting. “Is this Cal-OPTIMA institution trying to make the little man go out of [the Medi-Cal] business?”

“Never in 22 years have we had such unprecedented chaos,” said Lutsky’s wife and office manager, Susan, who called the meeting early this week to force some action from Cal-OPTIMA and legislators.

The county’s system--an acronym for Orange Prevention, Treatment and Intervention Medical Assistance--was created to cure some of the ills of which it is now accused. It is the largest Medi-Cal managed care system in the nation, launched to revamp a traditional system shunned by providers for its paltry payments and bureaucratic bungling.

Orange County’s much-touted model is a quasi-public system that pays set monthly fees per patient to Medi-Cal health plans. It brought in a host of new providers and medical groups--including health maintenance organizations such as Kaiser Permanente--to treat the county’s long-underserved Medi-Cal population of approximately 300,000.

Kathi Crowley, director of public affairs for Cal-OPTIMA, said she was disheartened and surprised by the outpouring of frustration she witnessed Thursday.

“Clearly, we’ve got some problems with individual physicians [among the 2,000 providers in the Cal-OPTIMA network] but I don’t think they are representative of widespread problems,” she said after the meeting, adding that further discussions are needed.

Doctors complained Thursday that since the system got underway in October, patients have been confused about who their doctors are, doctors have been confused about who their patients are and no one at Cal-OPTIMA seems to have any speedy answers.

The problem, they said, is that the system has so many layers. Cal-OPTIMA contracts with 36 health plans that in turn contract with providers who often are members of practitioners’ associations. A federal rule allows patients to change doctors once a month and those who don’t choose a physician eventually are assigned to one whom they might never have met before.

That, doctors say, makes it hard for anyone to know their status at any given time. A further complication is the fact that many Med-Cal patients do not speak English.

“We don’t know what [doctors’ group] the patient is from--the patient doesn’t even know. When you do the billing, it is so much of a headache,” said Dr. Alex Lin, a Santa Ana radiologist.

One obstetrician, Witoon S. Krailas, said he found out the day before a patient’s baby was due that the woman wasn’t his patient any longer. The woman, a Santa Ana resident, had been inexplicably assigned to a UC Irvine medical plan, Krailas said.

Others said they have not been paid almost since the inception of the program--and they don’t know where their money is because it could be stuck at any one of the bureaucratic tiers--with Cal-OPTIMA, with the health plans or with their practice associations.

“We are not sitting on any money,” Crowley said, adding that if individual health plans are withholding payments to providers “that will need to be looked into.”

Those who have been paid said their reimbursements are insultingly meager--as low as $11 for an office visit.

Physicians and office staff members say they have waited as long as 45 minutes on the telephone to obtain information from Cal-OPTIMA and, once the phone is answered, they have been treated rudely by staff members.

Crowley acknowledged Thursday there have been problems with Cal-OPTIMA’s automated telephone system, but said these problems have been identified and are being fixed. A system is being developed to allow providers to confirm patient eligibility with a swipe of a credit card. It is expected to be in place in a few months, Crowley said.

The confusion is more than an annoyance, physicians said. It is dangerous because something could happen to patients when they are in limbo between doctors and plans. Besides worrying about the welfare of their patients, doctors said, they are concerned about being sued for any mishaps.

Providers say requirements for participation in the program have been sprung on them with little notice, forcing them to revamp office procedures and invest hours in administrative tasks.

Susan Lutsky said her office received only 10 days’ notice before the staff was supposed to start treating AIDS patients--a population her husband and other primary care providers are not qualified to treat.

Some questioned why, when payments are so paltry, Cal-OPTIMA’s chief executive officer is drawing a salary of $170,000 per year plus a discretionary bonus of several thousand dollars.

“I think we need an audit of Cal-OPTIMA,” Santa Ana obstetrician Peter Park said. “Why is the CEO of Cal-OPTIMA paid so much?”

Others said they are suspicious of a system with so many “middlemen” and believe money for patient care is being eaten up by administrators. Cal-OPTIMA’s administrative overhead is capped at 6%, officials say--but providers said they suspect health plans are consuming much more than that.

Crowley said during the meeting--drawing some loud protests--that some providers seem to be resisting the inevitable advent of managed care, not Cal-OPTIMA in particular. But she said she emerged with the clear impression that at least a portion of Cal-OPTIMA’s individual providers do not believe they are being heard.

“I think it might make sense for us to establish some kind of forums for individual providers,” she said at the conclusion of the meeting. “The stuff you’re talking about has to be remedied.”