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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

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medi medi patients

MEDI – MEDI Patients

The Plan to Move to Managed Care, the Lessons of OneCare.

Satinder Swaroop, M.D.

the orange county experience
The Orange County Experience

Background:

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

(CMS).

the orange county experience3
The Orange County Experience

PHYSICIAN CONCERNS

Orange County physicians expressed concern about the

OneCare Plan for the following reasons.

  • Very short notice was given to physicians or the Medi-Medi patients that this was going to happen. As a result, there was little opportunity to provide input. The OCMA found out when one of the contracted Medicare Advantage physician groups prematurely mailed out letters with incorrect information in an effort to sign new doctors. Neither CalOptima or CMS had directly advised us of the plans to create the OneCare program nor was there a request for physician input.
  • Physicians believed that patient access would be negatively impacted. Patients that were default enrolled into OneCare would not be able to continue to see their physician of choice if they were not a OneCare contracted provider.
  • Patients would have a difficult time understanding the process and what they needed to do. Thus, they would be reassigned away from a physician they wanted to continue to see, when that was not their desire.
the challenges
The Challenges
  • Because of the short notice, physicians and other concerned parties had little opportunity to effectively respond.
  • CMS has made statements indicating that they want to eventually move all Medicare patients (not just the Medi-Medi) into managed care i.e. Medicare Advantage Plans.
  • TheOneCare Summary of Benefits that was presented to patients via the CalOptima website excluded the listing of Medi-Cal benefits (remember, these are Medi-Medi patients) and thus misled patients into believing that their OneCare options were much better than remaining in fee-for-service. The Summary should have included both Medi-Cal and Medicare benefits and given patients the complete picture.

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.

the challenges5
The Challenges
  • Default enrollment (or passive enrollment as termed by CMS) has been encouraged by CMS of Medicare Advantage Plan applicants as a way to ensure enrollment over patient choice. The plan was worked out behind the scenes and not shared with the public in advance. As a result, by the time OneCare was announced CMS already had plans to allow CalOptima to default enroll patients and strongly encouraged them to request approval to do so. Thus, default enrollment of patients was almost guaranteed for applicants.

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…”

the focus
The Focus

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 strategy
The Strategy
  • The OCMA lobbied CalOptima and CMS to let our concerns be known and convinced Members of Congress to write letters to CMS expressing opposition to the default enrollment plan. In addition we we invited the regional CMS Director to a town hall meeting of physicians to address our concerns.
  • The OCMA coordinated our efforts with the California Medical Association (CMA) which included sending a joint letter to the Director of CMS in Baltimore asking him to deny default enrollment.
  • The OCMA convinced CalOptima to implement a 3-month transition plan so that physicians would still get paid for a period of time for seeing their patients that were default enrolled away.
  • The OCMA instructed physicians to have discussions with their Medi-Medi patients to let them know what was happening and what they needed to do. Since physicians were the only ones with direct patient access, we used this to our advantage to make sure patients understood the process.
  • The OCMA convinced CalOptima to increase the number of contracted medical groups from 3 to 6, thus increasing the number of contracted OneCare physicians and insuring better patient access.
the strategy8
The Strategy
  • The OCMA mailed letters to physicians (OCMA Members and non-members) with helpful resources to help educate them and their patients on the changes in Medicare and the choices they would have to make.

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.

  • The OCMA organized several physician meetings with CalOptima to discuss physician concerns.
  • The OCMA organized a CalOptima Advisory Committee as a permanent part of the OCMA. This Committee includes both contracted and non-contracted OneCare providers, representatives of the contracted groups and CalOptima staff. We meet on a regular basis to discuss CalOptima and any issues and concerns physicians may have and work to develop appropriate recommendations.
sample letters
Referente a: Conservar el medico de su seleccion

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

siguientes:

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

opciones.

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

Dear Patient:

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.

Sincerely,

«Physician_Name», M.D.

SAMPLE LETTERS
the result
The Result
  • Patients opted out in large numbers (see chart on following slide)

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.

  • In the Vietnamese community alone, patients opted out in

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.

onecare cms mistakes
OneCare/CMS Mistakes
  • OneCare and CMS miscalculated the response of physicians and their patients to default enrollment. One week before default enrollment was to begin, OneCare believed that of the 55,000 Medi-Medi patients in Orange County they were going to end up enrolling 40,000 plus by default. That did not occur because in the last week patients by the hundreds opted out, which surprised a lot of people.
  • When enrollment began, OneCare enrolled about 20,000 patients, a little more than 600 had made the choice to switch to OneCare, the others were enrolled by default. This was at the very low end of the original numbers expected by CalOptima and which they had used to encourage their Board to support allowing them to move into the Medicare arena. That number did not last long, with current enrollment standing at about 7,800.
onecare cms mistakes13
OneCare/CMS Mistakes
  • CalOptima staff now admits it made a mistake by not involving physicians and the OCMA earlier in the process to try to work through any concerns and to make OneCare a viable program for patients and providers.

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.

recommendations for other county s
Recommendations for Other County’s
  • Be PREPARED – What happened here won’t stay here, it’s coming your way if it hasn’t already. Medicare has made clear statements that they want to move away from fee for service towards managed care (Medicare Advantage plans). Don’t wait for CMS to spring it on you, ACT NOW. Be AWARE, they know how to use DEFAULT ENROLLMENT and aren’t afraid to use it.
  • Physicians should start the communication with their Medicare patients and let them know what is happening. This includes not only the move towards managed care, but also reductions in physician payments that will impact patient access. This is critical that patients understand the obstacles that physicians are up against because WE ARE IN THE SAME BOAT.
recommendations for other county s15
Recommendations for Other County’s
  • County Medical Associations should develop FRIENDLY and ongoing RELATIONSHIPS with the area CMS personnel and to the extent possible keep on top of decisions that may be coming down the pike. Ask in advance for the opportunity to review and provide input on any communications that will be mass distributed to your patients in order to market new health plan options. This will help you to avoid any issues and to make sure that you are on the same page with CMS.
  • Physicians must keep UP TO DATE on what is happening in Medicare by being active members of the AMA, CMA and their local medical association and follow any actions that are recommended by these groups to protect their rights to see Medicare patients.