Orange County Register, by Brian Joseph –
December 18, 2012:
For months, doctors have warned that a state proposal to enroll 627,000 poor, elderly and disabled Californians into managed care would ultimately harm patients. The cost-cutting move – which would affect Californians who qualify for both Medi-Cal and Medicare in eight counties, including Orange – is still awaiting federal approval before it can be implemented, but one doctor says the state’s proposal has already severely injured one of his patients.
Dr. Kent Small, a Los Angeles County ophthalmologist and retina specialist, says his treatment of a 78-year-old patient was suspended for several weeks this fall after the elderly man apparently was coerced into enrolling with an HMO that limited the patient’s access to doctors.
Small said he diagnosed the patient with wet macular degeneration in September and ordered the man – an Armenian immigrant who doesn’t speak English – to come back in a week for treatment. Between the appointments, the man apparently received a phone call from someone representing the HMO. Small said the patient later told him that the caller told him that if he didn’t enroll with the HMO, the state would put him in another managed-care plan with restricted coverage. Frightened, the patient signed up.
But, Small says, when he later talked to the patient, he learned that the elderly man apparently wasn’t told the whole truth. For one, the state isn’t poised to put anyone into managed care because the feds haven’t signed off on the proposal yet. Small says the patient didn’t know that. Furthermore, if the feds do approve the state’s plan, patients will have the right to opt out of managed care. The man didn’t know that either, Small said.
Small also says the caller from the HMO apparently didn’t tell the patient that enrolling would restrict access to doctors. The doctor said it took his patient weeks to get his coverage changed back so the man could get the scheduled treatment. By the time the patient worked out his insurance, Small said, the man was legally blind in one eye.
Joya Bond,vice president and chief compliance officer for the HMO, Easy Choice Health Plan, said in a written statement: “Easy Choice takes quality of care and customer service very seriously. Our brokers are fully trained on proper enrollment and we have a rigorous process to ensure new members understand their plan and benefits. Additionally, all member grievances are investigated and typically resolved within two business weeks.”
Bond continued: “After careful review, we were able to confirm that during the month this individual was a member, we were unable to make contact to explain the plan or to address any questions – despite multiple attempts. We also were never notified, by the member or anyone else, of any concerns or grievances. The only communication was a confirmation of disenrollment with no further details.”
Small said he is troubled by the situation as it was described to him.
“These HMOs, they should be exposed and reprimanded,” said Small, who reports that a second “dual eligible” patient of his was also tricked by an HMO into unnecessarily enrolling for coverage. “They should be audited and penalized and held responsible (by) some authority or some agency,” he said.
Small’s other patient, Pilar Castelanos, is a 63-year-old American citizen who legally immigrated from Mexico City. She couldn’t remember the name of the HMO that called her, but she said the person she spoke with scared her into enrolling.
“They told me I was going to lose my Medicare,” she said. “I thought, ‘Oh my gosh, what am I going to do?’ ”
Patients who qualify for Medi-Cal and Medicare are, by definition, low-income and age 65 or older. They also tend to be immigrants and/or non-English speakers. That’s why doctors have been so opposed to the state’s plan: They say it preys on California’s most vulnerable patients.
And make no mistake, doctors suspect there are many more cases like that described by Small.
“The circumstances Dr. Small describes make every switch by a dual eligible to an HMO in the affected counties during this year’s Medicare open enrollment suspect,” said Dr. Craig Kliger, executive vice president of the California Academy of Eye Physicians & Surgeons. “I believe CMS (the federal Centers for Medicare and Medicaid Services) needs to review every single one of these to ensure there was no coercion.
“But worse, the fact that we already have evidence that a patient lost vision as a result of an unnecessary transfer is exactly why we are concerned about patients” who under the state’s proposal would be automatically signed up for a managed-care plan unless they actively opted out.
“Patient care will be disrupted with potentially tragic consequences,” Kliger said. He later added in an email: “(T)hese (HMOs) seem to be using fear of the details of the impending program as a marketing tool, and I think the state and CMS should have anticipated that.”
The Watchdog asked officials at the state Department of Health Care Services what they thought about Small’s cases and the possibility that patients may get misleading calls from HMOs. Spokesman Tony Cava asked the Watchdog for more details of the situation, saying, “We’d be happy to review this provider and any actions taken that resulted in patients being unable to access care and/or fraud.”
“The state has carefully reviewed and vetted the health plans involved in the demonstration,” Cava said in an email. “The demonstration has extensive protections in statute and in federal law to ensure patient safety and appropriate care.”