ICAAP and Medicaid Reform

Posted on: October 15, 2012

Since Medicaid reform was passed in January 2011, calling for a gradual shift to coordinated and managed care organizations (MCOs), ICAAP and partner organizations have held many discussions with the Illinois Department of Healthcare and Family Services (HFS) and other related departments.  At its last meeting with HFS in  August 2012, ICAAP continued to advocate for preserving the primary care case management (PCCM) program, and keeping providers informed of upcoming changes. In addition, ICAAP leaders advocated for increasing the quality of care provided by MOC, noting the current poor quality of managed care in Illinois and nationwide.

Our efforts are coordinated with the Illinois Academy of Family Physicians and the Illinois State Medical Society, as well as the more recent additions of the Illinois Hospital Association and consumer groups such as Illinois Maternal and Child Health Coalition and AARP.

The above mentioned groups developed and endorsed the Blueprint to Enhance PCCM in Illinois to provide guidance on how PCCM could be preserved by making changes that will improve care while meeting the intent of the Medicaid reform law.

Here are some brief updates from ICAAP.

- Despite what we believed was a well-thought-out proposal with support from many players, and agreement with HFS leadership on many principles, HFS stressed that the current model cannot achieve true care coordination and specialty care access.

- Identifying new coordinated care entities (CCE) and ultimately MCOs which already have systems, tools and networks for these purposes in place is needed.

- We reiterated our concern that adding many new vendors with different systems and generally poor track records will not be more successful than continuing to enhance the PCCM program HFS has established with strong provider input.

- A driving issue for HFS and the General Assembly is putting a firm ceiling on Medicaid costs, which is easier to do by paying fixed amounts to MCOs for care delivery than continuing to work with the PCCM on various improvements.

- HFS confirmed that in order to be contracted to serve HFS clients, an MCO (or CCE or Managed Care Community Network) must show an adequate network.

-ICAAP, HFS and partners discussed reluctance of providers to commit to new plans and networks.  As ICAAP knows, providers consider serious issues such as administrative hassles, payment, contracts, continuity with patients, and more before joining with new MCOs.

- We stressed the need to monitor MCOs’ quality of care, reimbursement, maintenance of network (including access to specialty care), and continuity as clients go from HFS to commercial plans via the insurance exchange.  HFS confirmed its intent to the patient’s current PCP to guide patient assignment as new programs roll out.

- HFS is committed to meeting the 50% requirement by 2015.  HFS will spend the rest of 2012 and 2013 enrolling complex costly patients, beginning in non-Chicago areas, as these are where care coordination could make the most difference.  Collectively these populations will be relatively small compared to the overall HFS population.  Then, in 2014, they will begin enrolling healthy adults and children.

- For calendar years 2013 and 2014, the Department of Health and Human Services (HHS) is proposing a rule that primary care reimbursement be brought up to Medicare levels, with the federal government picking up the difference.  ICAAP and its partners discussed how HFS would administer this increase, stressing our agreement with the government mandate that the payment ultimately  go to providers.  HFS is considering options for payment directly to PCPs (via fee-for-service), through MCOs , and as an add-on payment directly to the PCP after the service is reported to HFS. More information will be shared once HHS releases its final rule and HFS develops its plans.

ICAAP and its partner groups summarized concerns in a follow up letter to HFS sent earlier this fall.

For more information on these discussions or the state of Illinois Medicaid reform, please contact Scott Allen or Jennie Pinkwater at 312/733-1026, ext 202 or 213.