California health officials failed to ensure that more than 9 million residents enrolled in Medi-Cal managed care plans had access to doctors when they needed them, the state auditor said in a stinging report Tuesday. Health officials might have learned about those problems from calls to an ombudsman’s office – but thousands went unanswered every month.
Among the report’s findings:
Incorrect or missing data on provider networks meant that state health officials had no idea if the plans had sufficient doctors and specialists, or if patients got the care they needed.
An average of 12,500 calls to the program’s ombudsman went unanswered each month for nearly a year, frustrating patients’ efforts to resolve problems.
Provider directories for three health plans – Health Net in Los Angeles County, Anthem Blue Cross in Fresno County and Partnership HealthPlan of California in Solano County – contained inaccurate or outdated information, ranging from incorrect telephone numbers for providers to listings for providers who no longer participated.
Overall, state officials failed to verify insurers’ information about their networks of doctors and hospitals.
The audit’s findings come as little surprise to health advocates, who have called attention to these problems as California shifted millions of Medi-Cal recipients from traditional fee-for-service care which enabled enrollees to see most Medi-Cal providers, into managed care programs with prescribed networks of doctors and hospitals.
About 76 percent of the 12.2 million adults and children receiving Medi-Cal, California’s Medicaid program, were enrolled in managed care programs as of March 2015.
Eligibility for Medi-Cal, the state-federal health program for the poor, expanded under the Affordable Care Act. Since last year, more than 3.5 million enrollees signed up for the first time. Nearly one in three Californians now receive coverage through the program.
“The audit confirms longstanding concerns about issues of oversight of Medicaid managed care plans and of access to Medi-Cal services,” said Anthony Wright, executive director of the statewide advocacy group Health Access. “I think people on Medicaid are very appreciative of the care they get and it’s far preferable to be being uninsured. What’s troubling is the finding that we don’t even know if people have access. We’re two steps away from solving the problems that exist if we don’t know what they are.”
The agency “agrees with many of the state auditor’s recommendations” and already has begun to work on improving oversight, Department of Health Care Services Director Jennifer Kent said in a statement.
The agency is upgrading the ombudsman’s phone system to handle more calls and is taking other steps to ensure that residents can get medical care when and where they need it, she noted.
The state’s Department of Health Care Services contracts with 22 health plans to provide managed health care services to Medi-Cal recipients, who must choose from managed care plans available in their counties.
The audit singled out the performance of the Medi-Cal Managed Care Ombudsman’s office, noting that too few staffers, an inadequate telephone system and a glitch-prone computer system kept it from addressing complaints.
The telephone system rejected thousands of calls each month, ranging from about 7,000 to more than 45,000, between February 2014 and January 2015.
Even when calls got through, staffers were able to answer only a third to a half of them, the audit noted. A database to maintain information on the calls crashed frequently, resulting in further loss of data.
Efforts to improve oversight of Medi-Cal managed care plans are underway. The Department of Health Care Services is creating a “dashboard” of plan performance indicators to better identify problems in real time.
Pending legislation would require health plans to more frequently update their provider lists for all consumers, not just those on Medi-Cal.
A new state law also will require health insurers, including those serving Medi-Cal managed care patients, to provide data to regulators on how much time it takes for patients to get appointments with their physicians.
The audit noted that the Department of Health Care Services also needs to improve how it reviews primary care provider directories, which can affect children’s ability to get medical care.
“With nearly half of all children in California enrolled in Medi-Cal managed care, the state is responsible for ensuring that children are actually able to access needed health services,” said Alison Buist, director of health policy for the Children’s Defense Fund. “The audit confirms what advocates have long suspected: The state is not effectively monitoring whether health plans have enough providers to serve the Medi-Cal population, and the mechanisms to identify challenges beneficiaries face in accessing care are not working as well as they should.”
In a statement, California State Sen. Edward Hernandez, chairman of the Senate’s health committee, cited lack of funding as a key factor.
“While disappointing, the results of this audit are not surprising,” Hernandez said. “The systematic underfunding of Medi-Cal is making it very difficult for plans to set up adequate networks, and DHCS is not doing enough to make sure the commitments we’ve made to beneficiaries are being honored.”