It is usually after the mail arrives that Della Saavedra comes undone.
That's when she sits in her living room in this Los Angeles suburb and sorts through the latest letters from her health plan, each rejecting her appeal to stay with her trusted oncologist at City of Hope, a cancer center.
Saavedra, 53, a former cafeteria worker who suffers from bone marrow cancer, has been insured through Medicaid, the joint federal-state program for low-income people. She would go to any doctor willing to take her until last year, when the state revamped the program and assigned her to a managed-care plan with a restricted network of doctors. Her oncologist is not on its roster.
"I have been sick for years and no problem," Saavedra says. Then it became "a huge problem."
Saavedra is one of a large group of disabled Medicaid enrollees in California who have been moved out of traditional fee-for-service health coverage into a managed-care plan. The goal: determine whether these patients with complex medical needs receive better medical care while saving the government money.
The California experiment, in its second year, has national significance. Federal officials have begun to roll out a similar but larger effort required by the 2010 health care law, the Affordable Care Act. They will move up to 2 million of the nation's sickest and most expensive patients into managed care.
Twenty-five states have applied to be part of the managed-care experiment for these "dual-eligibles," people who qualify for both Medicaid and Medicare, the federal health program for seniors and people with disabilities. A typical dual-eligible is poor and older than 65 and suffers from chronic illnesses such as diabetes and heart disease. Massachusetts and Washington, the first states to be approved, will start their programs April 1.
Advocates for patients warn that managed-care plans -- some run by for-profit companies -- are ill-equipped to deal with the health needs of the elderly, mentally ill or disabled. Advocates are studying the experiences of patients such as Saavedra in California to see what the pitfalls of the national program may be.
"We have to think about the fact that people's lives are at stake," says Kevin Prindiville, an attorney with the National Senior Citizens Law Center.
Federal and state governments spend nearly $300 billion each year on the medical and home-care needs of patients who are enrolled in both Medicaid and Medicare. They account for 31% of Medicare's spending and 39% of Medicaid's spending, according to the Centers for Medicare and Medicaid Services.
"Medicare-Medicaid enrollees include some of the most chronically ill and complex enrollees in both programs," says Melanie Bella, who oversees the managed-care experiment.
The aim is to improve care of these fragile patients with better coordination -- saving money by eliminating needless tests and office visits and too many hospitalizations. Even so, the size of the experiment worries many. It's "too much, too fast, too soon," says attorney Vanessa Cajina, who has represented several patients in the California Medicaid managed-care experiment in her work with the Western Center on Law and Poverty in Sacramento. A recurring theme, Cajina says, is that the health plans did not have the range of specialists in their networks to care for people with complex or rare medical conditions.
Emma Sandoe, a spokeswoman for the Centers for Medicare and Medicaid Services, says the national experiment will have a safety hatch for patients: They will be able to opt out of managed care if they wish.
Experts say opting out is likely to be a daunting hurdle for many of these patients. "Fifty percent of duals either have cognitive impairments or serious mental illness. How's that going to work?" says Robert Berenson, a former vice chairman of the Medicare Payment Advisory Board.
A concern about the experiment involves patients who depend on home-health and personal-care aides. Community service providers say insurance companies that will run the program have little experience overseeing long-term, home-care needs of frail, isolated patients. Many insurers "wouldn't have had in-home supportive services," says Steven Wallace, chairman of the Department of Community Health Sciences at the UCLA Fielding School of Public Health. This includes patients who need support every week, not just the week they are discharged from the hospital, he says.
Health plans say they will be ready to meet the needs of the new members. "Plans are going to be covering services that they haven't done before," says Lisa Kodmur, program manager for seniors and people with disabilities at L.A. Care Health Plan. "It doesn't mean we can't. It just means we haven't done it."
Indeed, L.A. Care has begun to tailor its services by dispatching visiting nurses and medical assistants to members' homes to check blood sugar levels and blood pressure. It also promotes a 24-hour nurse hotline.
Steven Sample, 63, who suffers from a nervous condition and diabetes, praises L.A. Care. "My heart was beating really fast the other day, and I called and the nurse said to lay down," he says. "I would have gone to the emergency room if I didn't have the advice line."
And cancer patient Saavedra received good news last month from her health plan, L.A. Care. It gave her permission to go out of its network to her longtime cancer specialist.
Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a non-profit, non-partisan health policy research and communication organization not affiliated with Kaiser Permanente.
The following fields overflowed:
SIGNATURE = 2012-12-06-MedicareMedicaid-experiment-aims-to-save-on-care-for-poorest-sickest-patients_ST_U.xml
To see more of USAToday.com, or to subscribe, go to http://www.usatoday.com
Copyright 2012 USA TODAY, a division of Gannett Co. Inc.