Wednesday I hosted a webinar for Arc Exec’s on Coordinated Care. The speaker for this event was James Parker, Deputy Administrator, Division of Medical Programs, Dept. of Healthcare & Family Services. I have worked very closely with Jim over the years as the state has been moving forward on managed care. He is a great asset for the state.
In this past year the Dept. of Healthcare & Family Services has experienced exceptional growth and planning on managed care, coordinated care, Integrated Care Phase 1 & 2 , Medicaid Reform and preparing for the implementation of the Affordable Care Act. This is in addition to its regular responsibilities.
I asked Jim to assist us in understanding all of these new initiatives and how they all fit together. I also asked him to focus on opportunities for individuals with disabilities and provider organizations.
Jim walked us through a presentation that had been developed for use with legislators and was featured at a Town Hall Meeting in Chicago with Director Hamos.
Here are some of the highlights taken from Jim’s presentation and my commentary at the end.
For some reason, the system did not like my outline so I have highlighted sections of this presentation in red.
As the State is designing the Medicaid Healthcare System, the goal is to create integrated delivery systems that result in better health outcomes for children and adults in the Medicaid system. The centerpiece is care coordination. This effort initially focused on seniors and people with disabilities, the individuals with the most complex, expensive health, behaviorial and social needs.
Illinois has three different “managed care entities”:
Health Maintenance Organizations (HMO) traditional insurance-based, with full-risk capitated payments.
Managed Care Community Networks (MCCN) provider-organized entities, with full-risk capitated payments.
Care Coordination Entities (CCE) provider-organized networks, care coordination fees, medical/other services paid fee-for-service.
Integrated Care is about to begin statewide in Illinois for both Phase 1 (medical) and Phase 2 Long Term Supports & Services (LTSS):
April 2013 – Rockford region with 5,000 individuals
Central Illinois for 13,000 individuals
Quad Cities region for 1,900 individuals
Metro East region for 7,000 individuals
January 2014 – Chicago with 69,000 individuals
Opportunities for individuals in the new Care Coordination model include:
Multidisciplinary team focused on the individual’s total needs: health, behavioral health & social needs.
Care coordination assigned to help navigate a fragmented system.
Challenges for individuals:
You have to select one managed care entity from among two or more entities:
If you do not make a choice, you will automatically be assigned one.
People who are eligible for both Medicare and Medicaid (Duals) can opt-out of the Medicare medical service package.
You have to use the providers within the network.
You are locked in with the network for one year.
There are utilization controls in the network.
Opportunities for providers include:
Part of an integrated, comprehensive provider network with medical, behavioral healthcare and a variety of long-term supports and services (LTSS) not operating in isolation.
Part of a collaborative, multidisciplinary team focusing on the total needs of individuals to achieve better health outcomes and quality of life.
Challenges for providers include:
You will have to work with managed care organizations, rather than State agencies!
Unique care coordination design will mean multiple managed care entities in every region.
You will have to demonstrate your value and make connections with the managed care organizations.
You will have to learn different billing transactions.
You will have to learn multiple utilization control rules. You will be more accountable for performance and client health outcomes.
The state’s move to managed and coordinated care may be of benefit to children and adults who rely upon Medicaid for their healthcare needs. It is necessary that managed care for healthcare be robust and fully in place before we even discuss the managed care of developmental disability services. This train is moving way too quickly and as I look at the numbers and workload ahead for Medicaid Coordinated Care, I see trouble because the state’s infrastructure is very weak and relying upon very few dedicated staff. Integrated Care Phase 1 is only just now undergoing evaluation as the first year is now completed and far too many specialists, physicians groups and hospitals have not signed on to participate in Integrated Care.
The reform of the Developmental Disability System in Illinois continues to be the Governor’s Rebalancing Initiative and the “Blueprint for System Redesign”. We need a person-centered planning, a strong community provider system, individual budgets and real choice for individuals with intellectual and other developmental disabilities.
Clearly, Coordinated Care will have us working with managed care companies rather than the State agencies. In Wisconsin, there is no longer a Division of Developmental Disabilities. Will there even be a Dept. of Human Services in Illinois? Certainly there will be a restructuring of State Government.
In addition, our ability to advocate for our positions within the Governor’s Office and the General Assembly will be diminished or wiped out entirely. We will be subject to the profit margins of managed care insurance companies.
While there will be stronger appeal rights, there is nothing stated about independent ombudsmen in this new system. We need strong independent advocacy having the resources and teeth to advocate for children and adults with developmental disabilities to get the services/supports they need, like Equip for Equality.
We already have Care Coordination in the Developmental Disability System. It is the eighteen specialized freestanding Independent Service Coordination Organization for the people we support. This system was established by the Bogard Consent Decree, a Federal Class Settlement.
What about the 22,500 children and adults on the PUNS Waiting List? Will the waiting list be eliminated with Medicaid Managed Care?
Jim Parker stressed that discussions have not begun on implementation of Integrated Care Phase 3 because of all of the above activities. At the earliest, we are talking mid to late 2014 or beyond. The Arc, however, is not waiting. We have a work group on Managed Care and we are developing positions to oppose Phase 3 and protections that need to be in place if managed care moves forward. We hope to have our position finalized by May, 2013 and would like to hear your recommendations.