Medi-Cal patients sue state over being forced into managed care

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Advocates for low-income seniors and disabled people who rely on government-funded healthcare sued California officials Friday in Los Angeles Superior Court.  They want to stop the state from forcing Medi-Cal patients with severe, complex conditions into managed care, where they allegedly lack access to specialists they need.

A couple of years ago, California got permission from the federal government to shift more than 340,000 seniors and disabled Medi-Cal patients to a managed care group. The move was supposed to save the state $151 million a year, and provide the patients with more comprehensive care.

For patients, it meant they would be restricted to doctors on the managed care plan, with some exceptions: people with severe, chronic, and long-lasting diseases such as cancer or AIDS could request an exemption from the move.

California’s Department of Health Care Services granted 7,000 such requests, but denied 20,000 others, including one from Della Saavedra. The 53-year old says she ended up in a diabetic coma just months after state officials forced her into managed care.

“I was at my home, and my son was the one that found me,”  Saavedra recalled. “All I remember is telling him, ‘I’m thirsty, can you get me some water?’ And he said my eyes were behind my head.  He said, ‘Honestly, I thought  you were dying.'”   

The emergency room doctor who treated Saavedra said she would have died if she'd gone 10 minutes longer without help. Saavedra lays some blame on her managed care doctors for delayed test results.  The rest she attributes to “stress” from not being able to see doctors at City of Hope who had treated her for 20 years.

Saavedra, who also has cancer and hypertension, says her doctors requested an exemption from managed care treatment, but it was denied by the state. The explanation was that she failed to document “any high risk or complex medical conditions” that would cause her to suffer injury from a change in her care.

“The state is applying unwritten standards that the doctor and the patient don’t know about,” said Elena Akela, an attorney with the Legal Aid Foundation of Los Angeles, which is representing Saavedra and four other Medi-Cal patients in the county who were denied exemptions.

The Legal Aid Foundation  and the Western Center on Law and Poverty jointly filed a complaint in L.A. Superior Court Friday that accuses health officials of using “secret” standards to deny requests for opting out of managed care — regardless of the consequences.  

“If you have cancer,” Akela explained,  “and the doctor fills out the form...and they put the treatment codes in it, that’s supposed to be all that’s required to grant you an exemption.”

Akela says the Department of Health Care Services routinely decides whether patients can safely transfer to managed care, instead of deferring to patients' doctors.

“It’s up to the treating physician to say when their condition is such that they can be transferred to a doctor in managed care with similar specialties," Akela said. "But they just assume that you don’t meet the standard and then deny your exemption request.”

California’s Department of Health Care Services declined to comment on the lawsuit.

In a written statement the department said it “remains strongly committed to ensuring that Medi-Cal members receive the health services they need without interruption as they transition to the coordinated, efficient system of care in Medi-Cal managed care.”

Juan Cameros, 34, is another petitioner in the lawsuit and says his move to managed care was harmful.

“I couldn’t find a doctor in my medical group that knew how to treat what I had,” Cameros said. 

He suffers from chronic joint inflammation and a rare disease that causes fluid to build up in his knees. A physician at USC’s Keck School of Medicine successfully treated Cameros.

But after health officials rejected his request for a medical exemption, Cameros says managed care doctors cut his medication in half. Cameros was in so much pain he turned to emergency room doctors and his rheumatologist for help. They drained his knees — seven times.
 
“It’s not a recommended procedure,” said Cameros, “because every time they put a needle through your knee...there’s a risk of having an infection, or having a bacteria inside my knee, which is going to make everything worse.”

Petitioner Anita Valadez didn’t think her life could get much  worse, but the state transferred her to managed care a week before surgery to remove a cancerous tumor from her breast. Valadez was shocked.

“There was an emergency operation and then they send me all of a sudden to managed care," Valadez recalled. "And everything was being cut off.”

The 54-year-old also has Type-1, insulin-dependent diabetes, arthritis, blindness in one eye and she depends on a wheelchair.

Valadez was able to get her own doctors to perform the surgery, but afterwards the managed care physicians reduced the number of blood tests for her insulin levels below the required chemotherapy regimen. Now, she says, she has more to cope with.

“My cancer’s back,” she said through tears.

Valadez starts another round of chemotherapy Christmas week.  But she expressed relief that she’ll get that treatment from the doctors she trusts. 

Attorneys at Legal Aid were able to get Valadez and the other petitioners a one year exemption from managed care. They  hope by then the court will order state officials to follow the law as written.

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