By Joseph Franz
Beginning in April, San Diego will be one of the first cities in California to take part in the Cal MediConnect program. Cal MediConnect is part of an Affordable Care Act initiative intended to provide dual eligibles (Americans who qualify for both Medicaid and Medicare) with more effective care coordination at a lower cost to tax payers. Because Medicare and Medicaid have different rules, overlapping benefits, and conflicting financial incentives, there has been a lot of wasted money and a lack of care coordination for dual eligibles. By adopting private sector ideas, the goal is to reduce the cost of care while achieving better outcomes for patients.
The dual eligible patient is costly to the healthcare system. These people are usually, old, lower income, and have dysfunctional home situations. They make poor medical decisions by putting off preventative care; instead they choose to wait for a crisis before seeking help. This results in higher costs to the tax funded programs. According to an article on the
, although dual eligibles make up 15 percent of Medicaid enrollees, they account for 40 percent of costs. Similarly, they represent 20 percent of Medicare enrollees, but are responsible for more than 30 percent of all costs. This is because their disjointed care leads to treating symptoms while the root causes of their problems persist. The lack of communication between the two programs often lands patients in expensive emergency rooms when better options exist. The dual eligible program seeks to pay private sector HMOs to coordinate and manage the patients’ care, and the government and HMO will split the amount saved.
Wasted money is not the only negative by-product of the traditional treatment of dual eligibles; it’s also the quality of care.
gives an example of a dual eligible patient who has been delaying knee-replacement surgery, even though it has become a bone-on-bone situation, because of the constant challenge of navigating between several providers—some covered by Medi-Cal and some by Medicare. Also, doctors and homecare providers often don’t communicate efficiently regarding patients’ medication and the side effects to be aware of. This is why a patient care will be overseen by one HMO entity rather than several splintered groups.
San Diego will be offering five health plans through Cal MediConnect including Molina, Health Net, Kaiser, Care1st, and Comununity Health Group. The down side to the program right now is that patients can change their plan every month, which is a nightmare for the HMOs and providers to track. We hope this program is implemented better than Obamacare has been.
At Encinitas Nursing and Rehabilitation Center, we look forward to any initiative that promises to provide better care for our patients. If you have any questions about Cal MediConnect, visit
- For questions about skilled nursing and rehabilitation care of you or a loved one, please visit us at
or call us at (760) 753-6423.