Doctors urge feds to rethink plan for 'dual eligible' patients

Recently, we told you about a Los Angeles-area ophthalmologist who believes HMOs are coercing poor, elderly and disabled Californians into enrolling for services by spreading falsehoods about a new state proposal that would affect patients eligible for both Medi-Cal and Medicare in eight counties, including Orange.

In light of the doctor's allegations, one professional association that has opposed the state's plan is urging the federal government to not only investigate but also amend the California proposal. The feds say they're looking into the matter, but the association believes more must be done.

The conflict boils down to a single issue: California state government wants to enroll 627,000 "dual eligible" patients into managed care to save money. Patients who qualify for Medi-Cal and Medicare are, by definition, low-income and elderly.

The state's proposal calls for these vulnerable patients to be automatically enrolled into managed care for at least six months unless they specifically ask to opt out. For months, doctors have said this "passive enrollment" strategy is cruel, because these patients won't understand the significance of their enrollment. When you join a managed-care plan, often you have to change doctors.

That's why the California Academy of Eye Physicians & Surgeons is so upset about the recent disclosures by Dr. Kent Small, a Los Angeles County ophthalmologist and retina specialist. Small says that two of his dual-eligible patients were approached by an HMO that told them that if they didn't enroll with the HMO the state was going to put them in another managed-care plan with restricted coverage.

The HMOs apparently never told the patients that (a) the state's plan hasn't been approved by the feds yet, (b) even if it is approved they'd have the option of opting out, and (c) enrolling would restrict access to their current doctors. Both of Small's patients enrolled with HMOs before learning these facts, then had trouble disentangling themselves from their new HMOs.

Small says that one of his patients went legally blind in one eye while he was trying to separate himself from the HMO.

Dr. Craig Kliger, executive vice president of the eye physicians' academy, said these instances illustrate just how dangerous the state's plan will be for patients if it's approved as is.

Immediately after the Watchdog wrote about Small and his patients, Kliger sent two letters to the federal Centers for Medicare and Medicaid Services (CMS), requesting that the feds remove the "passive enrollment" component of the state's dual-eligible plan and review the instances in which dual-eligible patients in California have recently enrolled with HMOs, to ensure they weren't tricked into doing so.

"The fact that a non-English-speaking patient underwent an 'unnecessary transfer' resulting in disruption in his care for wet age-related macular degeneration and his becoming legally blind in one eye as things were 'sorted out' is fully analogous to what might happen if he had been involuntarily shifted via an 'opt-out,'" Kliger wrote in one letter.

Receiving those letters was David Sayen, the regional administrator at the Centers for Medicare and Medicaid Services' San Francisco office. He told the Watchdog that it's not unusual for HMOs to misrepresent the facts to potential enrollees. That's why the feds require HMOs to circle back with patients after they're initially enrolled to ensure they truly understand what they've done. Sayen said the feds closely monitor HMOs to ensure they actually do this.

In the case of Small's patients, Sayen said, the feds are investigating both matters, but simply don't have the resources to review every instance in which a dual-eligible patient recently has enrolled with an HMO.

As for Kliger's request to amend the state's proposal, Sayen said he couldn't comment because the feds have yet to rule on the state's plan, although he did add that he thought the proposal was important.

Sayen said he expects the feds to make a determination on the state's plan by the beginning of the year.

Kliger was less than enthused to hear what Sayen had to say.

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