OPTIMA’s Growing Pains Are Critical but Curable : Health Program Must Pay More Heed to Doctors’ Advice

Orange County long has had problems delivering health care to the poor, from the days when the county-owned hospital continually lost money to recent years when people waited until their health deteriorated to crisis level before seeking help. That meant higher cost for treatment in an emergency room than a preventive visit to a doctor’s office.

For their part, doctors treating poor patients complained about low payments from Medi-Cal, high paperwork loads and a daunting bureaucracy.

Four years ago, the Board of Supervisors approved a plan to create a network that would provide better care for the poor and answer the complaints of physicians. Unfortunately, the program was late getting started, was caught in bankruptcy-related problems and has not pacified all doctors. The administrators of what is known as Orange Prevention, Treatment and Intervention Medical Assistance Program--OPTIMA--need to do a better job of listening to patients and doctors and letting everyone know just what they are doing.

Two weeks ago several dozen doctors confronted OPTIMA representatives with their complaints. The turnout might have been higher had the meeting in a Garden Grove church not been organized so hastily.

Some doctors said they had not been paid for their services, though OPTIMA began four months ago. Some said they were unsure who their patients were, and patients were unsure who their doctors were.

Some problems are to be expected when a massive, innovative new program begins. But given the long planning time for OPTIMA, its missteps are disappointing. Doctors complained of being unable to reach OPTIMA officials by telephone. Being put on hold for 15 or 20 minutes is infuriating when dealing with a private company or a government agency; when it’s a doctor trying to get patient information, it is more serious.

The county’s old Medi-Cal system featured fees for services, with patients whose low income or disabilities made them eligible for Medi-Cal receiving treatment from doctors who were reimbursed by state and federal funds depending on services they provided. OPTIMA is a managed care program, increasingly popular in private companies across the country, especially in California, as a way to cut the spiraling costs of health care.

In managed care, doctors generally are given a flat fee per patient. That works well for the doctors when patients are healthy and seldom see a physician; the doctors do less well if they have to provide frequent treatment for chronically ill patients.

OPTIMA had $2 million tied up in the county’s fund hit by the bankruptcy, money it planned to use for start-up costs. Kaiser Permanente of Southern California provided a welcome $3-million loan last year to help bridge the gap. OPTIMA also was the target of complaints that it gave insufficient attention to Latinos seeking a voice in establishing the agency. However, the organization wisely has tried to ensure that doctors and patients from the county’s various ethnic communities are represented on its advisory committees.

The new program has caused problems of another kind for UCI Medical Center in Orange, which is again facing money troubles after several years of prosperity. Hospital officials said they enrolled fewer OPTIMA patients than they had expected; instead, many went to doctors elsewhere. The medical center replaced the county’s own hospital decades ago and has been the front-line provider of services to the poor in Orange County. Its financial health is in everyone’s interest.

OPTIMA officials will have to ensure that the doctors it counts on to treat the poor understand its mission and are satisfied that it can be accomplished without sacrificing good patient care. Other counties are watching the Orange County experiment to see if it reduces costs without harming patients. Listening to the health care providers should be the starting point for the new program.