November 1, 2002

Commentary

Alert For Seniors and Disabled Persons Who Currently Have Medicare and Medi-Cal

By Ben Medina, M.D.

The following is an alert concerning plans that are being proposed by San Diego County Health and Human Services that would affect seniors and disabled persons who currently have Medicare and Medi-Cal. The county is planning to begin voluntary enrollment but the long-term plan is to make it mandatory for those with Medicare/Medi-Cal to join a managed care plan.

In most cases, mandatory managed care would not be beneficial to patients. Several studies have documented that the poor and elderly fare worse in HMO’s and managed care plans, than they do in fee-for-service plans such as regular Medi-Cal and Medicare. Patients who are under the care of a specialist are particularly vulnerable because most managed care plans restrict access to services in order to control costs, and they limit the choice of providers. Many services that the patient needs (such as home health care, therapies, and durable medical equipment) may not be available under existing plans. Because managed care plans all work under the basis or obtaining prior authorizations before a service is rendered, delays are caused which increase the potential for medical complications, unnecessary hospitalizations, delayed diagnosis and delayed treatment. Managed care plans have very limited formularies for medications that are covered by the plan, which means the patient may have to pay for medication out of their own pocket. In addition, patients may be assigned a primary care physician and hospital that may not be near their residence, therefore creating more barriers to access and more transportation problems.

The Aged, Blind, and Disabled are increasingly dependent on health care services, but the managed care system does not compensate health plans for providing more care to patients with more complicated conditions or special needs. If you are a person in this category, think carefully before you exchange your Medicare/Medi-Cal for one of these “voluntary” managed care plans. If you want to ensure that you still have access to the best quality medical care in San Diego, your best option is to keep your fee-for service plan such as regular Medi-Cal and Medicare.

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