Proof of the COHS model’s ability to succeed is its application in the densely populated, ethnically diverse metropolitan county of Orange (population 2.4 million). Here, on October 1,1995, CaIOptima literally enrolled an unprecedented 180,000 Medi-Cal beneficiaries overnight. The plan has since grown into one of the largest Medicaid managed care entities in the United States.

While other COHS plans contract directly with individual physicians, CaIOptima has contracted with a network of privately operated health plans. Its providers fall into two major categories: health maintenance organizations (HMOs), and physicians/hospital consortia (PHCs). PHCs are affiliations between at least one medical group and one hospital. They are community based and unique to Orange County. Recognizing the value of the traditional (fee-for-service) physicians, community clinics and safety net hospitals, CaIOptima designed the PHC model to enable these providers to continue providing care to the Medi-Cal community. The CaIOptima provider network includes almost every major hospital in Orange County, community clinics and thousands of physicians throughout the county.

In addition to creating a system compatible with Orange County’s established medical infrastructure, CaIOptima launched a variety of innovative programs and services tailored to the needs of both members and providers. These include:

• A nationally recognized perinatal support services program offering family counseling, nutrition and prenatal education.
• A managed care information and outreach program to educate providers on managed care-related issues.
• Among the first programs in the country to service the needs of chronically ill and disabled members in a managed care setting. The program includes a new plan for increasing reimbursement rates to specialists and primary care providers serving members with disabilities.
• An enhanced program for administering complete services to approximately 5,000 CaIOptima members in long-term care facilities.
• A Special Needs Liaison Program to help members with special needs understand and more effectively access services within CaIOptima’s managed care system. The program also helps CaIOptima’s contracted health plans better understand the needs of the disabled.
• Multi-cultural instruction programs to assist physicians in serving individuals of different ethnic backgrounds.
• Cited in a national study as having a positive impact on the quality of care for Orange County Medi-Cal beneficiaries and for improving access to specialist physicians.

Since its establishment, CaIOptima has maintained a sound fiscal foundation, repaying all start-up loans ahead of schedule while accruing reserve funds for the development of new programs and services. In addition, a state audit released in the fourth quarter of 1997 gave CaIOptima an overall score of 95 percent based on the plan’s first year of operation. The audit noted that CaIOptima members’ access to care was excellent, as was the plan’s proactive efforts to assess and improve the quality of care its members receive.

Top of Page · CAHIO Member Plans