The state is not monitoring its Medicaid managed care plans to make sure they have enough doctors to meet patients' needs, an audit finds. And thousands of calls to an ombudsman were never returned.
The state pays insurers a fixed amount per enrollee and expects the companies to provide access to doctors and comprehensive care. But a scathing state audit released last Tuesday shows that California is failing to make sure those plans deliver. Many enrollees have insurance cards but often have trouble getting in to see a doctor.

The state didn't verify that insurers' directories of doctors were accurate, the audit found, or that the plans had enough doctors to meet patients' needs. The state Department of Health Care Services also didn't do its own required annual audits of the plans.

And thousands of phone calls to an ombudsman's office — created to investigate complaints — went unanswered every month.

The audit focused on three health plans, but underscores a broader problem in California: the lack of sufficient oversight of a program that now serves about 12 million beneficiaries, three quarters of whom are in managed care. Advocates and analysts say the state has moved too quickly to shift enrollees into managed care plans and given too much unsupervised responsibility to the companies.

While people enrolled in the old, fee-for-service Medicaid system sometimes had difficulty finding doctors, especially specialists, the difference is the managed care plans have a legal responsibility to provide sufficient access to their consumers.

The sheer number of enrollees, along with the complexity of their health care needs, means the state needs to do a better job tracking the plans responsible for caring for them, said Gerald Kominski, director of the UCLA Center for Health Policy Research.

"The audit indicates now that so many Californians are enrolled, how important it is for the state to have adequate oversight," Kominski says. "The state has a long way to go to reach that goal."

New proposed federal regulations designed to improve Medicaid managed care could help by requiring states to ensure that patients have enough access to doctors and hospitals. The regulations also would limit profit margins and establish a quality rating system for plans. In addition, a proposed bill in California would require plans to provide accurate and up-to-date provider directories.

The issue of managed care oversight isn't limited to California. Several states have transferred responsibility to managed care insurers but aren't closely tracking whether Medicaid patients are getting the care they need, says Joan Alker, executive director of the Georgetown University Center for Children and Families.

"This is a national problem," Alker says. "More beneficiaries with chronic and difficult health conditions and more public dollars are going into managed care. We absolutely need more accountability." - Read More at NPR

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