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Old 11-11-2010, 06:42 AM
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Default Riverside County: Worst record in state on Medi-Cal

Riverside County: Worst record in state on Medi-Cal

November 1, 2010

By JOHN GONZALES Center For Health Reporting and LORA HINES, The Press-Enterprise

Pregnant and diagnosed with thyroid cancer, Karina Hernandez went to a Riverside County social services office late last summer desperate for medical care.

Then she waited.

Despite placing dozens of phone calls to speed up her case, the 27-year-old Lake Elsinore area resident would not get approval for her Medi-Cal application for two months -- or two weeks past the 45-day federal deadline for processing applications.

"You do everything they ask you to do, and still it's not enough," said Hernandez, who added a handwritten letter to her lobbying effort as the deadline passed. "Sometimes, literally, I think they wish I would get sick enough and die."

No county in the state has a worse record than Riverside County when it comes to processing Medi-Cal claims on time.

County workers failed to meet deadlines for processing new applications in 30.8 percent of the cases according to a key audit this summer. That's three times the maximum allowed by the state. The county's record on disabled applicants was far worse.

It's a long-running problem. Riverside is the only California county that has failed to meet Medi-Cal enrollment deadlines every year since the current monitoring system began in 2004.

Also since 2004, the county has been swamped with a state-high 30 percent increase in beneficiaries for Medi-Cal, the government's health program for the poor and disabled. That has made it difficult for Riverside officials to serve the recession-stricken population in a timely way.

San Bernardino County, which has seen a 20 percent increase in applicants since 2004, has met standards every year.

Susan Loew, director of Riverside County's Department of Public Social Services, said county workers face a challenge as their caseloads "burst at the seams."

After reporters showed her the audits, Loew said the county submitted incorrect numbers. She said the slashing of state supporting funds has made it difficult to keep pace with Medi-Cal enrollment demands. Loew's staff has increased by 5 percent the last four years, according to department figures.

"Our challenge is to determine how we best restructure our services so we can minimize the need for customers to come in the office," Loew added, pointing to Web-based enrollment efforts and a new customer call center. Neither allows applicants to submit final supporting documents, including a birth certificate, to complete their case.

The bad news for Riverside County is that the workload will get heavier. In 2014, federal health care reform is projected to bring 1.6 million new applicants to Medi-Cal statewide, including an estimated 108,100 to Riverside County. San Bernardino County is projected to have 84,600 new applicants in 2014.

The Riverside County Department of Public Social Services said it had a caseload of 118,442 as of June 2010, which means health care reform could nearly double its responsibilities in 2014.

For the first time, working-class families will join low-income families as potential beneficiaries, and nearly everybody will be required to have some form of health insurance. The list of enrollment qualifications will be shortened, said state administrators. But they are asking how they will serve the influx with a system already on the brink.

"That's the fifty-thousand dollar question. ... I don't have a good answer for you today," said René Mollow, chief of the state's Medi-Cal eligibility division. "Health care reform in and of itself hasn't taken care of the resources issue."

Threat to health reform

Riverside County's problems provide a window into what some experts believe may be a fundamental threat to successful implementation of health reform.

In the future, insurance companies will shoulder some enrollment responsibilities, and state officials hope to move much of the application process to the Web with federal databases verifying place of birth, immigration status and income.

But there is currently no alternative to the paper shuffle of supporting documents now handled by bustling county social services offices. Even applicants whose paperwork is processed on time are discouraged by protracted waits.

Jennifer Thorpe, of Hemet, an unemployed student who suffers from Graves disease, said her application took an exhausting month to clear. While coping with the thyroid disorder, she had to badger county enrollment staff with phone calls and beg a lab to postpone billing.

"You go in the office and try to be persuasive and tell your story," said Thorpe, 32. "But you never feel a sense of urgency from anyone. They don't care."

Loew said her staff strives to be sensitive and efficient, but many applicants have difficulty finding their papers, or are slow in providing information. Some people give up because they don't want to reveal assets, including savings accounts and property.

"A lot of people don't realize how little you have to have to qualify for aid," Loew said.

Required by federal law

The auditing reports that revealed Riverside County's chronic problems are submitted to the State Department of Health Care Services every other year. They measure whether counties are meeting a 90 percent on-time threshold for Medi-Cal applications that is required by federal law.

Failure to hit 90 percent in any one category means the county did not meet the standards and must submit a plan to the state to correct the problems. San Bernardino County Medi-Cal enrollment supervisor Steve Couchot said his department meets standards by simply emphasizing the on-time completion of applications, and it has the same computer and case management system as Riverside County.

Riverside County failed to meet standards for the first time in 2004, when it processed disability applications at 78 percent. In subsequent years it did not meet standards for processing new applications.

The department's most recent report, submitted in July 2010 and analyzing some 9,000 applications, showed the worst performance yet. It found that only 70 percent of new applications were processed within the required 45 days; 76 percent of renewals were processed within the required 60 days; and just 39 percent of disability applications were processed within the required 90 days.

Tom Welch, the state's section chief of Medi-Cal program review, noted that Riverside County performs up to standards on one other audit: the accuracy of applications once completed.

Kimberly Lewis is a staff attorney with the Western Center on Law and Poverty, a Los Angeles nonprofit that has used the courts to force more efficient enrollment in safety-net programs. She was troubled by Riverside's performance -- and the state's oversight.

"It's not like there is a change here," Lewis said. "If anything, Riverside County has gotten worse."

Riverside County supervisors, who bear ultimate responsibility for the county's safety net, were unaware of the failed enrollment audits.

"I've not heard anything to believe it's a severe problem," Supervisor Bob Buster said.

The county applied in 2007 to establish a pilot program that is rich in federal matching funds and has since been redesigned to give municipalities a head start on implementing health reform. The application was denied after the state said Riverside County submitted a subpar plan to cover its population.

Buster said the county has no reserves to pay for such programs anyway, after years of dramatic cuts to the budgets of every department, including smaller reductions to law enforcement budgets. A controversial ballot measure to protect a pension plan for law enforcement would further weaken the county's legal obligation to abide by health care reform, he said.

"I hope we don't miss out on some opportunities for some matching funds," Buster said. "We have not done the job we should have done to keep an eye on this."

Applying for Medi-Cal in Riverside County means visiting one of 13 enrollment offices that dot the sprawling county. They are closed on Fridays because of budget cuts and are bustling the rest of the week.


Applicants take a slip of paper from a dispenser and wait for the number printed on it to pop up on an electronic screen, sometimes for as long as six hours, applicants said. A bundle of public assistance programs are offered, including general relief, food stamps, child protective services and Medi-Cal.

Medi-Cal enrollment requires supporting documents, including an original birth certificate, recent pay stubs, any deeds, even automobile registrations, to prove that assets do not exceed allowable limits. Medi-Cal enrollees must provide the documents every year for a renewal of the benefits.

During a recent interview, Loew continued to blame enrollment delays on program complexities rather than her staff. She held up a poster-sized list of 125 program codes that eligibility workers must use to qualify applicants for public assistance.

She said the list, used by all counties, needs to be chopped in half for her department to meet the demands created by health reform.

"Simplify the program," she said when asked what the state and federal governments could do to help Riverside. But that won't happen until new laws take effect in 2014.

Dozens of Medi-Cal applicants interviewed in Riverside said the county can't keep pace with their needs under the current system. They spoke of case transfers that undermined the hard work they did to provide supporting documents, and of county letters that sent them to enrollment offices that had been closed.

As Hernandez sought her prenatal Medi-Cal coverage, she was informed in a phone call from the county that the woman previously identified to her as her family's eligibility screener was not handling her Medi-Cal application. Hernandez said the county instructed her to call another number to find her screener.

Hernandez said she asked why no one had notified her sooner, because she made dozens of unreturned phone calls. She also delivered a handwritten letter earlier this month to her local Lake Elsinore public social services office looking for answers.

"They said they're too busy to call back," said Hernandez, who with her husband has sold a car, jewelry and furniture to support their family and come up with $525 for an ultrasound and biopsy.

Hernandez said that earlier in her pregnancy, a clinic doctor told her she would not be able to give birth to her child if she chose cancer treatment. Her lack of the ongoing prenatal care Medi-Cal provides could have led her to a terrible, uninformed choice.

Kim Irwin, spokeswoman for the UCLA's Jonsson Comprehensive Cancer Center, consulted Dr. John Glaspy about her condition for this story. In an e-mail, the oncologist said there was a course of treatment that would allow Hernandez to beat cancer and give birth.

"She could have her thyroid gland removed while she is pregnant. Then do the X-rays and the radioactive iodine therapy after she delivers," he said.

Hernandez, a mother of four, was finally enrolled in Medi-Cal seven days past her deadline. Loew and deputy director Sayori Baldwin insist that Hernandez is now fully covered, including cancer treatment coverage.

But even after the directors said Hernandez was covered, social services employees were still requiring Hernandez to return to the office with more income and residency proof. Hernandez said one employee told her to return with statements from four banks. Hernandez has only one bank account.

"Every single time they come up with something new," Hernandez said. "It's so out of hand. It's not OK."

Sent to a closed office

Sometimes, according to applicants, the county's efforts to innovate are only new sources of frustration.

When Loew established a new call center to facilitate Medi-Cal enrollment, her department did so by allowing the lease to expire on a social services office on Tequesquite Avenue in Riverside.

The office was closed in July. In August, Maria Caro, 53, received a notice instructing her to enroll her parents there.

On the hottest day of the year this September, she shuttled her 93-year-old father and 81-year-old mother to the empty facility. Her parents are so-called dual eligibles, low-income seniors who have their complex medical needs provided by Medicare and Medi-Cal.

After an hour of coaxing a father with Alzheimer's into the car, and a drive past a sparkling new social services office just blocks from her home, Caro discovered the closure. A flier on the whitewashed window instructed people in her ZIP code to go to the new office she had already driven past.

"I just don't get it. They make it so hard for you to enroll that it's almost as if they don't want to give you the help," Caro said, gazing at the notice and perspiring in the 109-degree heat. "They don't realize I have to put down all my other responsibilities to get my parents here."

Weeks later, Caro went to the office that was closer to her home all along, as she juggled her ongoing job search with taking care of her toddler grandson. She was told that if she already mailed in her materials, which she had, the notice was incorrect in asking her to go to any office in person.

An unemployed beautician whose husband works as a school janitor, Caro's immediate family is at an income level that will make them eligible for Medi-Cal under the new rules of 2014. But with the system already sluggish for her parents, Caro is unsure it will be of much use to her.

"It's frustrating enough trying to get them enrolled," she asked. "Is that what's in store for me?"

This project represents a partnership between The Press-Enterprise and the California HealthCare Foundation Center for Health Reporting. The center is an independent news organization that reports on health care issues of importance to Californians. It is based at the USC Annenberg School for Communication & Journalism and is funded by the nonpartisan California HealthCare Foundation.

Dyia Chacko, researcher, California HealthCare Foundation Center for Health Reporting, contributed to this report.

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Last edited by ilbegone; 11-11-2010 at 06:57 AM.
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