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Fixing the disconnect between Medicare and Medicaid to serve the most vulnerable Americans

June 27, 2014 at 6:27 PM EDT
Providing long term care at a reasonable cost — especially for low-income Americans who are elderly or have disabilities — has long been a challenge in the U.S. In California, long term care providers are coordinating in order to tackle the special challenges faced by those who qualify for both Medicare and Medicaid. Special correspondent Kathleen McCleery reports.

JUDY WOODRUFF: Next: another in our ongoing series about long-term care.

Providing that care at a reasonable cost, especially for low-income Americans and those who are elderly or who have disabilities, has long been a challenge.

The state of California is trying to tackle that problem, as special correspondent Kathleen McCleery reports.

KATHLEEN MCCLEERY: Eighty-five-year-old Lydia Cornell has diabetes, congestive heart failure, and has suffered multiple strokes. She lives with her daughter, Elsa, who cares for her and manages her medical problems.

ELSA MALIWAT: My mom sees like four different doctors, like her primary physician, who manages her diabetes, and then a cardiologist, because my mom had two strokes already. She also sees a nephrologist now because she’s been a longtime diabetic, as well as a podiatrist.

KATHLEEN MCCLEERY: After her husband died, Cornell exhausted her financial resources. Her low income allows her to receive Medicaid. California calls it Medi-Cal. And she gets Medicare too.

She’s one of more than a million Californians and nine million Americans who qualify for both. It’s an especially vulnerable group, says attorney and longtime consumer advocate Greg Knoll, CEO of the Legal Aid Society in San Diego.

GREGORY KNOLL, Legal Aid Society of San Diego: The population is our oldest. It’s our most infirm, our poorest group of folks. These are folks that are qualified by income for Medicaid. They also, because of their age or disability, are qualified for Medicare.

KATHLEEN MCCLEERY: Health care costs for this group are sky-high, far more than those on Medicare alone. Plus, the two programs, federally run Medicare and state-run Medicaid, operate separately, with different benefits and rules.

Ellen Schmeding directs aging and independence services for the county of San Diego.

ELLEN SCHMEDING, Aging & Independence Services, San Diego County: If you can imagine a disjointed system where everything that happens on the health side is in one silo, and the social services are in another, the two never to meet and talk, that’s what we’re really trying to address.

KATHLEEN MCCLEERY: California is one of 18 states trying pilot projects to fix that disconnect, all part of a provision of the Affordable Care Act.

The state launched a one-stop plan called Cal MediConnect beginning this spring.

Toby Douglas, director for the state Department of Health Care Services, overviews it.

TOBY DOUGLAS, Director, California Department of Health Care Services: What we’re doing under Cal MediConnect is combining all of these different programs under one umbrella, on one coordinated system, where individuals don’t have to do it and navigate multiple systems on their own. They will have one card, one system that coordinates their care.

KATHLEEN MCCLEERY: San Diego is one of eight California counties taking part in a three-year test of the new program. And here, most participants will be automatically enrolled in one of four managed care plans.

WOMAN: Good morning. My name is Meghan. I’m calling with Molina Healthcare.

KATHLEEN MCCLEERY: At Molina Health, care coordinators handle both medical and social needs by phone and in person, often in a variety of languages for this diverse community.

They work with a team of doctors, nurses and social workers. Molina’s medical director in San Diego ,Dr. Nora Faine, says one aim is to keep members out of the hospital and out of nursing homes.

DR. NORA FAINE, Medical Director, Molina Health of San Diego: It is going to help them to have a higher quality of life, because they are now going to know what the services are that are available to them, to be connected to them. Sometimes, there are transportation issues that are very significant, and people can’t get to both their physicians, their primary care physicians, their appointments, their specialists.

And so having transportation available to them, so that they’re not missing any of their appointments, making sure that if they have modifications that are needed in their home, grab bars, a ramp to go into their home if they use a walker or wheelchair, all of these services are part of coordinating their care. We’re really trying to make sure that people are able to stay into the community as long as possible.

KATHLEEN MCCLEERY: Another way to stave off costly nursing care is to make it easier for individuals to attend day health care programs.

DR. NORA FAINE: Someone can come and take advantage of the meals. There’s transport available to them. There’s therapy that meets their needs to keep them limber and more functional.

ELLEN SCHMEDING: If the care coordinator takes a look with the individual and together they say the day program would be a wonderful opportunity, then that’s something that the health plans can authorize. So, previously, that coordination might never have occurred.

KATHLEEN MCCLEERY: But integrating the two health systems hasn’t been easy.

LIZ LANDRAM, Poway Adult Day Health Care Center: It’s a great idea on paper, but the reality of it is that it’s not quite there yet, in I experience.

KATHLEEN MCCLEERY: Social worker Liz Landram at the Poway Adult Day Health Care Center spends hours each day helping those who are confused and worried about the changes.

LIZ LANDRAM: Many people are getting turned away from their doctors, saying that your insurance has changed, we can no longer see you, and this may be a patient who has seen this doctor for 30 years.

KATHLEEN MCCLEERY: That was Patricia DelVecchio’s experience. The former nurse waited eight months to line up knee surgery, only to discover her doctor won’t take the new managed care plan.

PATRICIA DELVECCHIO: I thought that I was going to get my surgery. He was getting verification. And I called up and I says, well, what’s happening?  Why am I not getting surgery? And they says, oh, we’re sorry. We don’t take HMO. So I’m very disappointed and very frustrated.

KATHLEEN MCCLEERY: The program isn’t mandatory. DelVecchio decided to opt out and keep her doctors who take traditional Medicare. And that’s a decision many other San Diegans are making.

Greg Knoll runs a call center that fields question about the fledgling program.

GREGORY KNOLL: In San Diego, we are told that our opt-out rate is in the 40 percent range. But you couldn’t prove that by me. When our advocates talk to people that are calling who are confused, even though we go through all the virtues of having their care coordinated, we have had virtually 99 percent immediately say, stop talking. I’m ready to opt out.

Most consumers are going to say, I’m going to stay with the devil I know, even if I got problems, than go to the devil I don’t.

KATHLEEN MCCLEERY: Elsa Maliwat, though, is betting the state will succeed with Cal MediConnect, and her mother is now enrolled.

ELSA MALIWAT: Even their insurance card — so, instead of like going to the doctor and showing, here’s her Medicare, here’s her Medi-Cal, here’s the supplement card, so now like she only carries one card for both Medicare and Medi-Cal. So, yes, it’s a lot simpler. That’s what’s I have been going through, yes.

KATHLEEN MCCLEERY: California officials acknowledge the new program is an ambitious one. They are hoping to enroll 450,000 people statewide by the end of 2015.

JUDY WOODRUFF: And you can test your knowledge of this online. Take our quiz to see how well you recognize the costs and the impact of long- term care. That’s on our Health page.