California Auditor Slams Medi-Cal for Poor Access; Advocates Cite Shift to Managed Care

Many Medicaid patients in California can’t find a doctor who will accept their coverage, and things have become worse since newly eligible enrollees have flooded the system under the Affordable Care Act (ACA), according to a highly critical report released Tuesday by the California State Auditor.

The report took aim at California’s Department of Health Care Services (DHCS), saying regulators failed to verify health plan data to ensure that adequate provider networks exist to serve Medi-Cal beneficiaries. More than most states, California has been faulted for not ensuring there are enough primary care physicians and specialists to meet patient demand, which escalated due to Medicaid expansion. Some regions are worse than others.

The audit found that DHCS has not consistently monitored health plans to ensure they are meeting patient needs, and when patients try to complain, they may not even get a return call. In fact, complaints from beneficiaries to the state ombudsman may not even be heard; an average of 12,500 calls per month went unanswered between February 2014 and January 2015, according to the report.

For healthcare advocates, the blistering findings were confirmation of what they have observed for more than a year. A dual problem has occurred, they say: millions of new enrollees joined Medi-Cal under the ACA, and at the same time, new and existing beneficiaries were shifted from fee-for-service to managed care plans with narrow networks of doctors and hospitals. Some say provider fees were cut during the 2008 recession and never adequately restored, leaving too few to care for too many.

The audit found that directories for 3 plans—Anthem Blue Cross in Fresno County, Health Net in Los Angeles County, and Partnership HealthPlan of California in Solano County—contained inaccurate or outdated information, such as incorrect telephone numbers or providers who had dropped out of the plan.

These kinds of problems are among the many issues that have been addressed in a massive proposed rule issued in late May by CMS, which seeks to improve consumer access and protections as managed care becomes the norm in Medicaid in most states. Among the many items in the proposal, CMS calls for states to monitor network adequacy by setting time and distance standards, as well as separate standards for pediatric, behavioral health and dental care. CMS has called on states to look at ratios used by commercial insurers as benchmarks in securing the number of providers to ensure network adequacy.

California’s unique regulatory framework includes DHCS’ oversight of the 22 Medi-Cal plans and separate regulation of Managed Health Care, and the State Auditor called for better coordination between the agencies.

Among other recommendations from the State Auditor:

· By September 2015, the DHCS must establish a better process for determining adequacy of provider networks.

· By September 2015, the DHCS must coordinate with Managed Health Care a process for checking network adequacy through the MHC’s quarterly assessment of provider networks.

· DHCS must review each plan’s process for updating and ensuring the accuracy of provider directories. Several recommendations dealt with the matter of inaccurate directories.

· Develop and adhere to a new auditing schedule that complies with state law.

· Find a way to eliminate overlap with Managed Care Services.