Complaints don't materialize about management of Orange County's CalOptima medical program for the poor

Monday, Oct. 31, 2011 | Orange County Supervisor Janet Nguyen caused an uproar this month when she abruptly proposed major changes to CalOptima, the county's $1.3-billion program that provides medical coverage to about 430,000 poor adults and children.

She said dramatic alterations to CalOptima's nine-member governing board were needed immediately because of the many complaints she'd received since January, when she became the supervisors' CalOptima representative.

She said she was approached by those unhappy with the program even while buying gasoline and attending a birthday party.

Yet records show CalOptima received only five complaints during the past four months relayed by the county's top elected officials from their constituents, a spokeswoman said.

When asked last week how many complaints she received, Nguyen said she didn't keep count. Asked what she did when she received a complaint, she replied, "I listen to it."

She said she and her staff also "try to work with CalOptima" to get information for those voicing concerns.

Margaret Tatar, executive director of public affairs for CalOptima, said the organization has a grievance hotline and like other large insurance groups receives numerous complaints.

In addition, she said, CalOptima staff meets quarterly with the staffs of county supervisors and the county's members of the Assembly, state Senate and House of Representatives.

Tatar said the offices of elected officials are encouraged to relay complaints to CalOptima.

In fiscal 2009-2010, she said a total of 15 complaints were forwarded by all five supervisors, 14 state legislators and six members of Congress. In fiscal 2010-2011, which ended in July, there were 19 complaints, and so far in fiscal 2011-2012, there have been five.

"We have a whole department that handles grievances," Tatar said. Federal and state laws governing Medicare and Medicaid, the program for the medically indigent, require specific grievance systems and documentation.

Trying to Change the CalOptima Board

Early this month Nguyen proposed major changes to the composition of the CalOptima board that would have given control to businesses and providers and reduced the influence of groups that represent the poor who use the medical services.

Currently the board has three seats for consumer groups and three for medical providers, including a doctor. There also is a seat designated for business, one for the county's Health Care Agency and one for a member of the Board of Supervisors.

Under Nguyen's proposal, two of the three consumer seats would be replaced by seats for private business. The current business seat would go to a representative of the county Department of Social Services. The three existing provider seats would remain, but one would be specifically for hospitals, one would continue to be for doctors and the third for either clinics or health networks.

The result would have been eight of the nine seats representing a business, a provider or someone in county government and only one representing consumers.

Nguyen, according to critics, wanted to further dilute the voice of consumers by requiring that the consumer seat be held by someone who uses CalOptima, not by a nonprofit that represents them.

Opponents of that plan say an individual volunteer representing the poor would be no match for the sophistication and resources of providers, business interests and county officials.

Nguyen also wanted to give her 1st Supervisorial District a permanent seat on the CalOptima board because, she said, about 40 percent of those in the county who are eligible for its services live in her district.

Following the outcry that accompanied her initial proposal, Nguyen now says her plan is open to modification.

She held a four-hour open forum last week, but only enough people attended to use half of that time. Nineteen doctors, health network, clinic, hospital and other providers gave brief presentations, most urging Nguyen to give their group its own seat on the CalOptima board.

She also heard from 16 speakers, most representing nonprofits that work with low-income and disabled patients, like the Legal Aid Society, Alzheimers' groups and Adult Day Health Care, who voiced opposition to cutting the nonprofit consumer seats.

Budget Realities

Beyond the commotion created by Nguyen, the CalOptima board will discuss at its regular meeting Thursday how to deal with the state's planned 10 percent reduction in payments to providers.

Federal approval of California's cuts for doctors was announced last week, but Tatar said CalOptima wasn't immediately provided all details. In earlier discussions, the board proposed delaying the cuts until Jan. 1, if that is legally possible, and using reserves to absorb interim costs.

The state also has applied for federal permission to require copayments from patients and to limit the number of doctor visits for each patient. Those requests are pending.

While the financially strapped state has been trying to limit the cost of medical care for the poor, recent studies show Medicare and Medicaid fraud perpetrated by clinics, doctors, pharmacists and other medical providers has spiked in recent years, reaching $60 billion a year nationwide.

Last week, for example, federal officials indicted 16 people associated with a Glendale medical clinic, including a doctor and the owners of a San Marino pharmacy, in connection with an $18-million scheme to defraud Medicare and Medi-Cal.

In this case and in other typical examples, some patients were paid for the use of their Medicare and Medi-Cal billing information, according to a news release from the U.S. attorney's office in Los Angeles. Those included veterans, the homeless, low-income patients and the elderly, the release said.

The medical providers used the patient information to repeatedly bill Medicare and Medi-Cal for drugs the patients never received.

"Many other beneficiaries had their identities stolen and used in the fraudulent scheme without their knowledge," the news release said. "As a result of the drugs being fraudulently dispensed in the names of those beneficiaries, some were denied Medicare and Medi-Cal coverage for drugs that they legitimately needed."