MEDI – MEDI Patients. The Plan to Move to Managed Care, the Lessons of OneCare. Satinder Swaroop, M.D. The Orange County Experience. Background: In 2005, CalOptima, the Medi-Cal managed health plan in Orange County, announced that it was establishing a new
The Plan to Move to Managed Care, the Lessons of OneCare.
Satinder Swaroop, M.D.
In 2005, CalOptima, the Medi-Cal managed health plan in
Orange County, announced that it was establishing a new
Medicare Advantage plan called OneCare. OneCare was
designed to enroll Medi-Medi patients in a Medicare
managed care plan away from fee-for-service Medicare.
In order to obtain the necessary number of patients to
operate the program, default enrollment of patients (also
referred to as passive enrollment) was promoted and
approved by the Centers for Medicare and Medicaid
Orange County physicians expressed concern about the
OneCare Plan for the following reasons.
CMS approved this document stating that it was not appropriate to include Medi-Cal benefits since it was a Medicare document. CalOptima confirmed that including the Medi-Cal benefits would have left OneCare at a competitive disadvantage to fee-for-service.
At the urging of the OCMA, the CMS Regional Director agreed that the document was incomplete and advised CalOptima to make revisions.
In an April 29, 2005 memorandum to Medicare Advantage Plans the CMS wrote “We strongly encourage organizations that are submitting new SNP proposals to submit the required passive enrollment information…”
Because there was inadequate advanced notice given regarding the creation of OneCare, the OCMA’s options in fighting the proposal were limited because most of the decisions had already been made or were being finalized. In reviewing the entire program it became clear that the focus of the OCMA should be on fighting the default (passive) enrollment of patients away from their physician.
In response, the OCMA developed a dual track strategy to fight the default enrollment. However, we knew we were fighting an uphill battle and were being told by multiple inside sources that the decision to allow default enrollment had already been made by CMS.
Nonetheless, we fought hard to make our case and while default enrollment was later approved, it was obvious that our pressure on CalOptima and CMS caused them to delay the announcement until they had heard us out. It also bought us time to educate physicians so they could educate their patients on their choices.
The resources included communication tools such as draft
Letters in Spanish, Vietnamese and English for physicians to
share with their patients describing the OneCare process and
what patients had to do to express their choices. The materials
also included talking points for physicians that they could use
when talking directly to their patients.
Por la presente me dirijo a informarle de los cambios de Medicare y de
como indicar su decision de permanecer bajo mi cuidado medico.
En octubre recibira la carta de Center for Medicare and Medicaid Services
(CMS) informandole los cambios en la ley de Medicare y las opciones
para seleccionar el plan de recetas medicas. Las opciones son las
Continuar con el proveedor actual en forma de arreglo
tradicional de Medicare y seleccionar el plan de recetas
medicas o de varios planes que se le ofreceran, o tambien:
Cambiarse al Medicare Advantage HMO llamado
OneCare. Este le asignara el medico como tambien el plan,
ya establecido, de recetas medicas. Se le informa de que si
usted selecciono participar en el programa OneCare no va
poder escoger al medico o el plan de recetas medicas.
En vista de que no tengo contrato con la red de OneCare, la unica forma
en que usted puede permanecer bajo mi cuidado medico es
respondiendo a la correspondencia de CMS (Centers for Medicare and
Medicaid Services) y hacer saber su decision de continuar en el programa
tradicional de Medicare. Si usted no responde a la carta de OneCare e
indica su seleccion, comenzando desde el l de enero 2006 se le signara,
automaticamente, a la red de OneCare y al medico.
A causa de si usted desea continuar bajo mi cuidado medico, debe
responder a la carta de OneCare y dar a conocer la decision de
permanecer en el plan Medicare tradicional. De esta manera, se
conserva nuestro arreglo actual y se asegura de continuar cibiendo
cuidado medico de la mas alta calidad. Si usted decide permanecer en el
plan Medicare tradicional, tendra que escoger Part D para recetas
medicas. Para poder saber cual es el plan de recetas medicas que mas le
conviene, le puedo ayudar a revisar los planes desponibles o puede
entrar a la pagina de internet CMS ((http://www.cms.hhs.gov) y ver las
Lo aprecio como paciente y espero que tome la decision de que pueda
seguir bajo mi cuidado medico. Si tiene alguna pregunta, llame al telefono
del consultorio que aparece arriba de esta pagina. Se le agradece su
atencion a este asunto tan importante. Espero de que pueda seguir bajo
mi cuidado medico. Atentamente,
RE: Maintaining Your Physician of Choice
This letter is written to inform you of changes in Medicare
that have the potential to impact your choice of physician
and could result in the assignment of you to another
doctor without your permission. To avoid having this
happen, I am writing to request that you indicate your
decision to continue seeing me so that you are able to
maintain your continuity of care.
In the next few weeks you will be receiving a letter from
OneCare. OneCare is a new Medicare Advantage Plan
offered by CalOptima. In the letter, OneCare will give
you the option of selecting to participate in their provider
network or to stay in private care (also referred to as fee-
for-service) and continue to utilize me as your physician.
Since I am not a contracted physician in the OneCare
network, the only way you can continue to see me is if
you respond to the OneCare solicitation and indicate that
you want to remain with your current physician in fee for
service. If you do not respond to the OneCare letter
and indicate a choice, you will AUTOMATICALLY be
assigned to the OneCare network and a network
physician beginning on January 1, 2006 and will no
longer be able to see me.As a result, if you wish to
continue to see me you must respond to the OneCare
letter and indicate that you want to remain in fee-for
service Medicare. This maintains our current
arrangement and will insure that you continue to receive
the highest quality of care.
I value you as a patient and hope that you will make the
choice to continue our relationship. If you have any
questions, please feel free to contact my office at «Physician_Phone».
Thank you for your attention to this important matter. I look forward to
continuing to be your physician.
«Physician_Name», M.D.SAMPLE LETTERS
from OneCare either before being default enrolled or after.
As of September 2006, OneCare enrollment continues to
decline as patients decide to opt out and return to their
original physician. This is 9-months after the implementation
of the default enrollment process.
very high numbers in a large part due to the communication
effort conducted over local Vietnamese radio instructing
patients of their choices. This took CalOptima and CMS by
surprise and they are still trying to recover by running their
own advertisements in the Vietnamese media in an effort to
convince them to enroll into OneCare. To date this effort has
been less than successful with disenrollments still significantly
outpacing new enrollments.
The OCMA has helped to use that admission to further develop a relationship of open communication with CalOptima and to avoid future surprises which may have a negative impact on physicians and their patients.