A Very Good Report Card

Orange County’s health plan for the poor has had its share of birth pangs since starting operation two years ago, but its ratings in a state audit released this month are impressive.

Known as Cal-OPTIMA, the program was devised by the state to shift medical service for those eligible for Medi-Cal benefits because of low incomes from traditional fee-for-service to managed care. That sort of shift has been underway for the general population for years now, with California a leader. The objective is to curb the costs of medical care. Those who enroll in managed care plans usually first see a primary care physician, who then decides if more assistance is needed and provides referrals to specialists. In fee for care, patients see the doctors they choose and pay more to do so.

Cal-OPTIMA has been one of the country’s largest managed care systems since beginning in October 1995 and has been looked at as a model for other counties and other states. There were complaints during the organizational process that some doctors would not be included in the system and that Latinos could have difficulty finding service. More recently, advocates for the handicapped have told of less than smooth sailing in getting care.

But the audit of operations in the first year found that the medical care was good and patients were able to get the care they needed. State regulators visited 10 medical offices and reviewed records of more than 250 patients for the audit. Cal-OPTIMA has about 230,000 patients.

The audit gave the health plan an overall score of nearly 95%. While there were occasional criticisms that documentation was lacking for some patients, there were also perfect scores for access to health services and for the program’s effort to assess and improve quality. Cal-OPTIMA has made efforts to ensure that patients could continue seeing their doctors after the program began. Doctors and hospitals formed health plans that bid for Cal-OPTIMA contracts. That was an important move to gain doctors’ acceptance of a new program.

The Board of Supervisors is preparing to have the health plan also provide care for the working poor who are not covered by Medi-Cal. The state scrutiny of care delivered in doctors’ offices and of pharmacies’ dispensing of the proper medications should be reassuring to those involved with the Cal-OPTIMA system. The audit also has provided a valuable service by noting those areas where the health plan, while working well, still can do better.