BY Charlene Muhammad
Charlene Muhammad, Sentinel Contributing Writer, wrote this article with support from New America Media’s California Dual-Eligibles Fellowship Program, sponsored by The SCAN Foundation.
HIV/AIDS advocates for elderly, Black women infected with the disease in Los Angeles County are urging Department of Health Care Services (DHCS) to increase its outreach and awareness about a new health program called Cal MediConnect to their vulnerable population.
LaWanda Gresham received her blue envelope from DHCS announcing the new health plan for elderly and low-income people in L.A. County, but she didn’t know what to do.
The 61-year-old is one of 200,000 dual eligibles – meaning recipients of both Medical and Medicare – who qualified for enrollment into a coordinated-care health care system across the state. Although deemed mandatory, people – especially those with an HIV/AIDS waiver – can opt out of the program, which is what Gresham did.
“I didn’t understand it all, so I took it to my doctor,” said Gresham. “I found out I wouldn’t be able to continue seeing my doctor. I would need to switch to a doctor [who is ] under the plan,” Gresham said. Her doctor elected not to join Cal MediConnect, she said.
However, Cal MediConnect has an option which allows primary care doctors or specialists to sign up temporarily. Doctors could continue seeing their patients for six months for Medicare services and 12 months for Medi-Cal services under several conditions:
Their patients have to have seen them twice in the 12 months before they enrolled in the plan. Their doctor must be willing to work with the plan and accept payment from them; and their doctor can’t be excluded from their plan for quality or other reasons.
Gresham felt she would also be cut off from some viable programs, and other visits would be controlled to minimized visits, like twice per year instead of as needed.
“I was confused. I was scared all over again. I went through all these years to take this stupid medicine, which I’m tired of taking but I take it. I have arthritis and bone density problems. I need to put drops in my eyes everyday, and now this,” Gresham lamented.
Frightened yet determined, she then took her packet to her case manager at the Minority AIDS Project. Together they called Cal MediConnect and planned her next steps.
Her primary task was to get more education about California’s Coordinated Care Initiative, the large state program including Cal MediConnect, enacted as part of the state’s 2012-2013 budget. She knew very little basic and critical information about the program the state said was designed to improve health care for people like her, she said.
She is worried that Cal MediConnect’s requirements take her away from the combined Medicare and Medi-Cal services she’s spent years coordinating herself.
“But after I personally spoke to them and asked [them] not to transfer me, but stay, they said okay,” Gresham said through a sigh of relief.
Gresham has learned through trial and error how to make her Medi-Medi network serve her, but some of her peers haven’t and they need to be on Cal MediConnect to benefit from the consistency and benefits being offered, she stated.
She hopes DHCS steps up its efforts to inform her peers and seniors in general about what’s required and offered through Cal MediConnect. She’s begun reaching out to her peers to inform them about it.
Cal MediConnect has approved health insurance plans for L.A. County, including LA Care, Care More Cal MediConnect Plan, Care 1st Cal MediConnect Plan, Health Net Cal MediConnect, and Molina Dual Options.
Currently, consumer and provider outreach and education includes training beneficiaries and other stakeholders in their networks. In addition, the National Senior Citizens Law Center offers a webinar series and in-person trainings on California’s Coordinated Care Initiative. Fact sheets, the community outreach calendar, and updates are also available at CalDuals.org.
The California Department of Aging has received a $1 million grant from the Centers for Medicare and Medicaid to support outreach, education, and one-on-one counseling to Cal MediConnect beneficiaries.
Gresham questioned how the new program will tend to HIV seniors’ care network needs, because papers get lost between providers, she said.
“You can’t package us all in one thing because the needs are different and the facilities are different. For instance, at a county hospital most only have a certain amount of time they provide HIV doctors in those hospitals, then they’re somewhere else. People flip out by then,” she exampled.
Many become frustrated and turn to drugs or alcohol, Gresham continued. “A lot will depend on this program. If it’s explained right, this program will help some people, if it’s explained right and not rushed,” she urged.
That’s how she got confused, Gresham reflected. “I was given this paper. I was told to do this. I was told to do that and I’ve got 30 papers in here and I don’t know what I’m signing, what I’m reading. So that’s where it collapses when it gets all in my hands because I don’t know what to do with it.”
Joyce Lister, 76 and a dual eligible South L.A. resident, admits sometimes due to substitute carriers, her mail often gets lost, so she hasn’t received a blue envelope yet. However, she’d still heard nothing about the Cal MediConnect program through her providers or case managers.
While she’s receiving adequate care, Lister said she wonders what other benefits may exist through Cal MediConnect. “I’m anxious to read what it says and what the program is all about,” she stated. The little she knew came from Gresham after she was interviewed for this project.
Tina Henderson, Ph.D, program manager at the JWCH Institute (Wesley Health Centers), said she was unaware of the program as well. In her five years at JWCH, she’s worked to help locate HIV positive homeless women and link them back into medical care, specifically Black and Latino women whom the Cal MediConnect program will heavily impact.
“Unfortunately, the message is not getting out. Somehow, people think that it’s not something that needs to be discussed. I think the campaign about informing African Americans needs to be upgraded severely,” Henderson said.
Part of the problem is discussions around HIV have decreased drastically, particularly pertaining to Blacks, she noted.
“You’re dealing with a very, very sensitive population who has supportive needs that are not being met, like just being able to know and connect with others experiencing something similar,” Henderson said of elderly, Black women with HIV.
“It’s more than just going to the doctor. It’s going to the doctor, but there are days where because medication can be very toxic, you may not feel like going to the doctor and it increases as people get older and experience additional health ailments,” Henderson continued.
She added, “If you’re not treating the whole person, you’re still missing a big part of what their needs are … I could see people falling through the cracks. You can hand them some medication but what about support groups and connecting them to someone they can call and talk to when the medication is impacting them.”
A big challenge even with programs such as Cal MediConnect is they’ve designated HIV a specialty disease when it comes to Black women or seniors, said Phil Wilson, executive director of the Black AIDS Institute, said
“As a result that allows them to do a number of things that are actually harmful for people living with HIV,” such as raising co-pays and premiums, and not having lower prescription benefits, Wilson said.
Even programs that link people into care doesn’t solve the problem because the care they’re linked into, particularly for HIV, ends up being too expensive for them to carry, he continued.
Dual eligibles are some of the sickest and more needy individuals – need more time and services in a doctor’s office, noted Richard Butcher, M.D., Medical Director, Multicultural Primary Care Medical Group in San Diego.
“It is a noble and daunting task to say, ‘Let’s get our hands around everything to get a coordinated program to get everything to them in Southeast San Diego,’ but currently the ratio for them is one physician for every 2,000 patients, he said, referring to Cal MediConnect’s roll out in North County. That compares with as low as one doctor in 200 in affluent areas, he said.
Dr. Butcher continued the question for any new approach such as Cal MediConnect is “will it give us a better medical system once it is in place?”
“Unfortunately,” duals can opt out. They will not have the benefit of coordinated care if they do so and continue on with two doctors, one for Medi-Cal and one for Medicare. This still needs to be addressed, Dr. Butcher continued. One solution is to ensure services get to needy communities in a timely manner, he offered.
Dr. Butcher applauds the transportation components of the program, which enables key beneficiaries to get to their doctors’ appointments and on time.
At her age and with her condition, Gresham said she chose to opt out because her current plan covers a range of services in a network that gets it, and that’s not worth the loss in transfer. But that’s just her story, she reminded.
Her fear also hearkened back to HMO/managed care early days when people were restricted to other doctors and the networks weren’t connected.
“I may have to wait or go to the emergency room and it’s hell in the ER rooms – which look like cities – if you’re HIV positive … I don’t want the run around, because that’s why a lot of people fall out of care,” she said.
Gresham feared losing in addition to her HIV specialist, her physical specialist, chiropractor and eye doctor.
“I have a network now. I finally have something that works together. Everybody knows what’s going on with me. They speak to my specialist. A doctor can approve or disapprove of treating you and I get treated,” she rejoiced.