CPMA Director Expresses Concerns Over Roll-Out of Dual Eligibles Demo Project

CPMA Director Expresses Concerns Over Roll-Out of Dual Eligibles Demo Project


After numerous delays California plans to roll out its dual eligibles demonstration project in seven California counties on April 1, affecting roughly 400,000 older Californians who qualify for both Medicare and Medi-Cal. A pilot project of that size and scope is bound to have a number of difficulties and attendant concerns, and this project certainly has, and continues, to face its share. The California Podiatric Medical Association’s (CPMA) Immediate Past President Dr. Karen Wrubel, a podiatric physician and surgeon said the initial launch targeting almost half of the state's one million duals doesn't seem much like a pilot project. Dr. Wrubel how is also a member of the state Board of Podiatric Medicine (BPM) pointed out that none of the 14 other states in the national demonstration project are of similar size or scope. She said the inevitable result of transitioning so many people will be that some will fail to receive the same level of care they're getting now or they will fail to have that care paid for.

"I've worked in managed care for 20 years, and I've seen instances where people move into new health plans and suddenly they can't see the same doctor or get the same care," said Dr. Wrubel, whose practice is in Hawthorne, Los Angeles County.

With this high need, often cognitively impaired population gaps in coverage or payment can be dire, Wrubel said.

"We just see patients being confused and overwhelmed. No one seems to know what's happening, even DHCS. Managed care can be an appropriate choice, but when they're being enrolled with their passive consent, they have no way of knowing how to navigate the system," she said.

Wrubel is concerned that many of the beneficiaries won't know what's happening to their coverage and will likely just show up in their providers' facility and want to know why they can't see that particular provider anymore.

"All of these people being switched at once, it's going to harm people," Wrubel said. "They show up at the doctor's office and they can't be seen. So they say, 'Why can't you see me?' or 'Why can't you get paid?'"

She said that happens on a relatively regular basis in her practice. "This has happened over the years. We just expect it will happen more now," Wrubel said.

Wrubel has three main concerns:

  • LA Care, the largest health plan participating in Los Angeles County, has been excluded by federal officials from passively enrolling dual-eligibles. LA Care had a quality rating that dipped below CMS standards. So now that passive enrollment slack will be taken up by three other plans -- CareMore, Care 1st and Molina Healthcare. "We haven't met with any of these plans or gone through the vetting process for any of them," Wrubel said. "LA Care is certainly the largest. How can they not pass the readiness review, but these others can? That makes no sense." If adding three new health plans increases choice, Wrubel asked, "Then why wasn't that the case in the beginning?"
  • Because of the many delays -- some ordered by federal officials -- the transition has many start dates, further muddying the waters for beneficiaries, Wrubel said.
  • The biggest issue, Wrubel said, is the process for beneficiaries to opt out of the project. CMS requires that dual-eligibles in the California demonstration have the right to remain in the current fee-for-service system and not participate in the managed care project. DHCS officials discussed either an opt-out form or an opt-out box on other forms, but instead the state will issue a form outlining beneficiaries' choices. Wrubel and other advocates are worried the form will not adequately explain the opt-out option.

David Gorn, California Healthline 2/18/2014