The California Department of Justice’s Medi-Cal Fraud and Elder Abuse Unit is conducting a criminal investigation after receiving a new tip regarding Contra Costa County’s Enhanced Care Management (ECM) program, according to sources close to the investigation.
The tip came from the U.S. Department of Health and Human Services’ Office of Inspector General, they say, and cited NBC Bay Area Investigative Unit’s May report about the county’s ECM program allegedly ignoring patient medical needs and, as a result, causing patient harm and deaths. In that NBC Bay Area report, the Investigative Unit spoke to Contra Costa County public nurse manager Irene Graham who said she initially tried reporting her concerns internally but county officials failed to listen and retaliated against her.
Enhanced Care Management is a new state benefit worth billions of dollars that is supposed to treat California’s most vulnerable Medi-Cal patients, including the unhoused and low-income seniors. It’s supposed to treat the whole patient, including their social and medical needs.
Graham said, since 2022, Contra Costa Health Plan’s ECM program has been cutting corners and dangerously ignoring ECM patient medical needs. She and Contra Costa Health’s spokesperson at the time, Kim McCarl, confirmed with the Investigative Unit, the county has only been addressing social needs like housing insecurity and mental health. McCarl said another department arm of Contra Costa Health (CCH) handled ECM patient medical needs, which is not how the ECM program is designed, according to the state.
Emails show, last year, Graham reported falsified medical documents to county leaders. Patient visits, she told them, were labeled and billed to the state as “Public Health Nurse Visits” when either no visit took place or it was handled by someone without medical experience. Graham told NBC Bay Area she saw these inaccuracies herself.
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The problem resulted in serious patient harm, Graham reported. She told CCH officials and county supervisors about an ECM patient dying after his bed sores turned into a bone infection. Another patient, she wrote, died after receiving no health interventions for a year.
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NBC Bay Area reached out to Contra Costa Health, including their CEO Anna Roth. CCH refused to answer our questions saying the issue is a confidential, personnel matter. However, earlier this year in a February 2024 interview with NBC Bay Area, CCH's spokesperson at the time responded.
When asked about concerns that nurse visits were actually being conducted by staff with no medical training, CCH spokesperson Kim McCarl said, “I guess there is no real implication to that. We don’t charge differently. We don’t necessarily care differently.”
Roth never responded to our news organization’s request for this story.
Regarding the DOJ’s criminal investigation, CCH told NBC Bay Area it is not aware of any investigation.
Separately, the California Department of Health Care Services (DHCS) said it is conducting its own audit. In an email, DHCS spokesperson Anthony Cava told NBC Bay Area, “Resolution of the identified issues remains in progress” and that it’s their “understanding that [Contra Costa Health Plan] has begun to implement some measures to address concerns.” However, until their audit is complete, “DHCS cannot confirm whether all issues have been fully resolved.” DHCS said their audit report should be released in January.
DHCS issued one finding, however, where Contra Costa County’s Enhanced Care Management did not properly classify patient complaints, which the county said it’s fixed.
Graham said she doubts all the issues have been addressed because she was retaliated against when she first came forward internally, and CCH did not start taking action until her attorney and media got involved.
Without admitting guilt, Contra Costa County reached a $499,000 settlement with Graham after she complained to the California Labor Commissioner’s Office that her CCH higher-ups retaliated against her for coming forward.
“They screamed at me and told me to watch out,” she said. “They called the [sheriff’s office] and had me escorted out…both [to] shame me and then also use me as an example to make other people be quiet and not raise concerns.”
NBC Bay Area reached out to CCH about this, and the agency, again, would not comment saying it’s a personnel matter.
Contra Costa Health’s Public Health Director Ori Tzvieli recently wrote a letter saying, “CCH acknowledges Irene Graham has demonstrated dedication to patients’ care and has made notable contributions to the ECM Program.”
Jayme Walker is Graham’s attorney. She has specialized in whistleblower cases her entire career and says she’s never seen anything like this letter, especially since she and Graham had not yet filed a lawsuit against Contra Costa County. She said she’s hopeful there will be positive change.
“Nothing was done until I, as a lawyer, and you as a journalist got involved,” Walker said.
Graham still believes in ECM and public health programs that serve vulnerable patients. She quit her job with the county but says she hasn’t quit fighting for patients, her fellow nurses and for public health.
“We should spend money on these issues. They’re important issues, but we just need to make sure that it goes to the right place,” she said.
Catch up on our first report:
Part 1: Whistleblower: Contra Costa Health is cutting dangerous corners, harming Medi-Cal patients
Candice Nguyen is the investigative reporter on this story. If you have a comment on this report or if you have another investigative tip, email her at candice.nguyen@nbcuni.com.
