Plans to move more than 2 million California Medicaid beneficiaries into managed-care programs are raising fears among community groups about the quality of service those consumers can expect to receive.
To ensure the effort will be responsive to the public's needs, California Health Decisions, a statewide, not-for-profit consumer advocate group based in Orange, is helping to design Orange County's Medicaid managed-care system, CalOPTIMA.
Although many states are expanding their Medicaid managed-care programs, it's unusual for consumer advocates to have the opportunity to influence a health plan practically from the moment of its conception. CHD hopes its role will serve as a model for the integration of Medicaid into managed-care statewide.
"We try to bring the voice of the underserved to the table," said Ellen Severoni, president of CHD. "We need to find out what Medicaid beneficiaries think about their care."
About 900,000 Medi-Cal recipients are enrolled in some form of managed-care program. Medi-Cal is California's Medicaid program.
"By the time our programs are fully implemented, we project to have about 3 million-or about half our total Medi-Cal eligibles-enrolled (in managed care)," said John Rodriguez, deputy director of California Health Services.
Co-founded in 1985 by then-registered nurse Ellen Severoni and bioethicist Corrine Bayley, CHD works to help consumers cut through the jargon surrounding healthcare issues and involve them more actively in the reform debate.
In November 1993 CHD conducted a series of focus groups on Medicaid issues in Los Angeles and Orange counties. The characteristics found to be most important to Medicaid beneficiaries-respect, fairness and quality of service-are being designed into CalOPTIMA.
Orange County's Board of Supervisors recruited Severoni in 1993 to chair the health plan's Member Advisory Committee, funded primarily from grants acquired by CHD. Donating her time, Severoni had an opportunity "unlike any other" to design CalOPTIMA from the ground up.
Under Severoni's leadership the Member Advisory Committee, composed of Medicaid beneficiaries and community advocates, made sure community views were part of the plan's design options; request for proposals; and statement of mission, goals and objectives.
"What makes CalOPTIMA unique is that the Member Advisory Committee is built directly into the decisionmaking process," said Mike Stockstill, the plan's director of public affairs.
Beginning Oct. 1 Medi-Cal beneficiaries will be allowed to choose health plans and providers, and they will be able to switch at any time if they're not satisfied.
CHD is also having an impact in Santa Clara County, one of 19 California counties targeted for the movement of Medi-Cal recipients into managed care.
In 1994 the group helped San Jose-based Good Samaritan Health System, which has three hospitals and a total of 900 beds, shape its community-planning initiative. The outreach program included a series of focus groups that helped Good Samaritan rate its staff's ability to deal with the diversity of the San Jose populace. It also helped develop a method to audit the cultural competence of its service departments.
"We'd had marketing focus groups before but never community focus groups," said Molly Coye, M.D., senior vice president of health system development at Good Samaritan.
CHD representatives assisted in designing the focus group format and training Good Samaritan staff to conduct the meetings and process the results.
As CHD celebrates its 10-year anniversary, Severoni says the group is "needed now more than ever" to help people make educated personal choices, especially in the complex environment of managed-care systems.
"It is in the best interests of the presidents of HMOs to make sure that their members are educated about the choices they make. It's too expensive if they don't," she said. "Today's managed-care environment encourages customers to take more personal responsibility for their own healthcare. To do that they need the information. Personal responsibility and system accountability go hand in hand."
While not-for-profit CHD receives some direct payment for its consulting work, it relies mainly on funds from its board of directors and contributions from philanthropic organizations to meet its $425,000 annual budget.
Severoni is also president of American Health Decisions, CHD's national parent, which has chapters in more than a dozen states.