CalOPTIMA’s Success

Three years after its launch, Orange County’s health care program for the poor and disabled continues to get good marks. Federal officials, who foot the bills, say they are optimistic the program can be used elsewhere, reducing medical costs but not the quantity or quality of medical care.

The designers of the program, known as CalOPTIMA, deserve credit for mapping an uncharted path. The administrators have done a good job identifying problems and solving them. The doctors and hospitals have smoothed over differences and formed cooperative programs. Advocates for the indigent have monitored the care provided to the poor.

The creation and functioning of CalOPTIMA, which replaced Medi-Cal in Orange County in October 1995, have been carried out in public. That’s as it should be. Taxpayers provide the funds, about $500 million this year, and medical care for the county’s 200,000 poor and disabled people is an important public issue.

There are still concerns about some parts of the program, which substituted managed care for traditional fee-for-service. Managed care has become familiar to most Americans in recent years, as private insurers and companies move toward health maintenance organizations in an effort to control the growth of medical costs. The need for lower costs and a system that worked better was what prompted federal, state and county officials to try to adapt the HMO system to treating the poor.

One concern CalOPTIMA needs to heed is ensuring that the disabled get care from the proper specialists. Another is determining how to measure the quality of health care it delivers, rather than relying on anecdotes about coverage. To their credit, program administrators have shown they are aware of what needs to be done.

In the days before CalOPTIMA, many in Orange County who qualified for Medi-Cal had difficulty finding doctors willing to treat them. The doctors complained payments to treat the poor were too low. As a result, many of the poor went to hospital emergency rooms for maladies that could have been treated just as easily in a doctor’s office. That’s much more expensive than preventive care.

Getting patients access to doctors and cutting down on the time spent in hospitals were two of CalOPTIMA’s goals. Those objectives have been met, with no evidence that medical care has suffered.

Program administrators did a good job of letting patients keep seeing their regular doctor when they had one. Health maintenance organizations and cooperatives of doctors and hospitals were told they had to keep a high percentage of doctors who had been treating Medi-Cal patients if they wanted to get contracts with CalOPTIMA.

Last year, the program said that 85% of those doctors still were treating the poor and disabled. That’s an important reflection of medical professionals’ satisfaction with the new system.

Five years ago, only about 1,900 doctors in the county treated Medi-Cal patients. Today about 5,000 physicians, 85% of the total, are in plans that treat CalOPTIMA patients. That’s another encouraging sign that the program is working.

Also noteworthy is the dramatic drop of nearly 50% in hospital-based care, primarily emergency rooms, from 1993 to 1997. Some hospitals have suffered from the loss of patients, but program administrators have tried to funnel patients to doctors at two of the biggest, hardest-hit facilities, UCI Medical Center and Children’s Hospital of Orange County.

CalOPTIMA has announced plans to require its 17 health plans to collect data on subjects, such as immunizations and prenatal care, to measure health care delivery.

If it continues to earn good reviews from patients and doctors, it deserves to be replicated in other counties inside and outside California.