Medi-Cal patients adjusting to managed care system.

Never mind educating L.A.'s Medi-Cal recipients on the intricacies of managed care, Just teaching them how to make and keep doctor's appointments is enough of a challenge.

L.A. County officials are discovering as much as they move the county's Medi-Cal population from the traditional fee-for-service care into two, more cost-efficient managed care plans.

One of those plans will be run by Foundation Health Systems of Rancho Cordova, Calif., and the other is being run by L.A. Care Health Plan, a state-mandated health maintenance organization set up in 1995 to handle Medi-Cal patients.

All parties involved - as well as the state - are implementing strategies to educate the poor about the workings of managed care. Still, most of the efforts so far have been patchwork and largely uncoordinated.

Those efforts range in scope from a state-sponsored day-long seminar for new Medi-Cal recipients, to educational seminars, phone calls and hot lines being set up by managed care providers.

Many of the efforts will likely require tweaking and adjustment in the years ahead.

Officials from Foundation, L.A. Care and their various subcontractors said that re-educating Medi-Cal recipients to use managed care systems poses a formidable challenge.

"Most Medi-Cal recipients have inappropriate health-seeking habits that have been reinforced by the system because they never got any education (on proper health care habits)," said Clyde Oden Jr., president of United Health Plan, one of seven subcontractors working under the L.A. Care Medi-Cal plan.

Oden, who has worked with Medi-Cal recipients for the last 24 years, said teaching the poor to practice preventative health care through regular visits to their primary care doctors will be one of the biggest challenges.

He said many of L.A.'s poor have never accessed the health care system through primary care physicians, who, under most managed care plans, act as the gateway to specialists and hospital care.

"Most (Medi-Cal recipients) were given a Medi-Cal card and told, 'Good luck,'" Oden said. "We'd often find them flocking to inappropriate sites, such as emergency rooms, to receive care."

"These people have never been in managed care - they don't understand (the concept of) a primary care doctor," said Mario Molina president of Molina Medical Centers Inc., a subcontractor with Foundation in the L.A. County MediCal program. "They're used to going to the emergency room for their primary care."

Molina said the old fee-for-service Medi-Cal system - which provided little guidance for individual recipients - didn't encourage preventative care, which led many recipients to put off treating their problems until those problems reached crisis proportions.

Cultural factors, such as a reluctance by many Asian women to undress in front of a doctor, also discouraged many Medi-Cal recipients from seeking preventative health care.

In addition to educating the poor to be more preventative-minded, HMOs that cater to MediCal recipients are also saddled with more-mundane challenges, such as simply getting their members to make and keep appointments. Oden said.

"The issue of time and being prompt is different for many of these patients. For many of them, time is more relative, and tomorrow is a long ways away from now," he said, explaining that many Medi-Cal recipients are more focused on day-to-day issues and have less time for long-term health concerns.

In their drive to change the health care-seeking habits of L.A.'s poor, Medi-Cal HMOs have adopted a number of tactics, including making a concerted drive to get out accurate information about how their plans work.

Most Medi-Cal HMOs contact their new members shortly after signing them up and encourage them to attend group or individual meetings to learn about the various services available to them. Some HMOs have also set up toll-free multi-lingual information phone lines for new Medi-Cal recipients with questions.

Molina said the two biggest challenges of communication by phone are language - since many Medi-Cal recipients don't speak English as their native language - and the fact that many poor people don't have easy access to phones.

The state is also getting in on the act, setting up its own toll-free hotline and hiring an outside contractor to conduct educational sessions in recent months.

The information blitz owes in part to the complexity of materials Medi-Cal recipients receive when they enroll in the program, said Lynn Kersey, director of Maternal & Child Health Access, an education and counseling service for pregnant women and their families.

"(On enrolling in the MediCal program), the patient gets a packet of information that's two inches thick," she said, noting that the materials were only recently translated into other languages besides Spanish and English.

In addition to receiving information that is either too complex or in a language they don't understand, many Medi-Cal recipients have reservations about managed care because of misunderstandings about their entitlements under managed programs, said Sean O'Brien, director of MediCal operations at Foundation.

"There's a misunderstanding that you'll get fewer benefits being in a (managed care) health plan," he said. "A lot of people feel that being enrolled in a health plan will cause them to lose other benefits they're used to."