Patients suffer from insurance companies – Capitol Weekly |  Capitol Weekly

Patients suffer from insurance companies – Capitol Weekly | Capitol Weekly


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posted 02.08.2024

OPINION – There is a crisis in Orange County, one where the most vulnerable – seniors with disabilities, single mothers, families living below the poverty line – have lost access to vital health care services.

The focus for all involved must now be on patients – those who are facing turmoil, worse health outcomes, longer distances to travel for care and a much greater burden on their families. For these vulnerable Californians, their worst fears have come true.

As one patient wrote, “I recently turned 76 and suffer from COPD and find myself going to West Anaheim Medical Center at least three times a year. I was told that West Anaheim Medical Center may not be able to take I don’t have CalOptima insurance and it has scared the hell out of me. I can’t drive and I only live two blocks from West Anaheim Medical Center so I’m able to walk to the hospital when I have problems.”

This shouldn’t happen in California and it doesn’t have to.

Here’s what’s happening: CalOptima, Orange County’s Medi-Cal managed care insurer, has eliminated four major safety-net hospitals from its network — those that care for people experiencing homelessness, substance use disorders, chronic health conditions and more. This sudden change was made with little notice and went into effect on Monday, February 5th. Whatever CalOptima’s reason for dropping these hospitals, we know it’s being done by an insurer that’s holding on to a nearly $700 million surplus. The State Auditor has reported that it should be used for patient care and expanding access.

If this situation is not resolved soon, everyone in Orange County — not just those covered by CalOptima — will face significant challenges in accessing the health care they need and deserve. With CalOptima cutting off access to these four hospitals, the burden of care for Orange County’s most vulnerable patients is now shifting to the remaining local hospitals at a time when they are already challenged with limited emergency department and hospital capacity. This unnecessary barrier will lead to harmful delays in accessing needed medical care and additional overcrowding in emergency departments.

Orange County is not alone in facing this access to care crisis. In December, as the Central Valley grappled with a massive rise in respiratory illnesses — COVID, flu and RSV — major insurance companies abandoned their responsibility to patients, denying patient transfers, delaying responses to doctors, failing to keep a sufficient number of qualified nurses. facilities to accommodate patients, and more.

In that situation, state regulators stepped in to require these insurers to fulfill their obligation to patients. Regulators must do the same in Orange County and avert a crisis before patients suffer.

This is a bigger problem and one that will grow in the coming months and years. Across the state, insurance companies like CalOptima that continue to deny physician-directed care are booking record profits while patients are left in the lurch.

A 2023 survey found that about 4,500 patients each day stay in California hospitals and emergency rooms despite being discharged from medication. Patients in managed care plans are left dependent much more often than those with fee-for-service insurance coverage.

The cause of this problem: insurance company delay or refusal of authorization for care.

The result of this is that each year, hospitals provide about 1 million days of unnecessary hospital care due to discharge delays and 7.5 million hours of unnecessary emergency department care. This directly contributes to at least $3.25 billion in avoidable health care costs each year.

It’s time for state regulators to take action to preserve access to care for Orange County’s most vulnerable patients.

And it’s time for insurance companies in the state to put patients above premiums and reaffirm their commitment to the lives entrusted to them.

Carmela Coyle is President and CEO of the California Hospital Association

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