After the 2015 Open Enrollment Period 347,300 Illinoisans purchased plans through the marketplace, and 541,000 people have enrolled in Medicaid since its expansion in 2014. While connecting individuals to coverage is good news, the newly insured are often overwhelmed by having to navigate the overly complex healthcare system and understand the related insurance and medical jargon. This confusion and lack of experience counteracts one of the healthcare reform law’s major goals: to reduce medical costs by increasing access to primary care. Obtaining coverage will not offset a lifetime of avoiding the doctor’s office and visiting the emergency room for primary care. The newly insured must learn how to find a doctor, fill a prescription and read a prescription label. Without that, they are subject to poor health outcomes and high costs. The newly insured must gain health literacy which can only happen through the combined efforts of consumers, communities, providers and governing bodies.
What is Health Literacy?
The Centers for Disease Control and Prevention define health literacy as the degree to which an individual can obtain, process, communicate and understand health information and services. People with low health literacy are more likely to be uninsured. Similarly, uninsured individuals show lower health literacy scores compared to those receiving employer-based coverage.
So Why Does Low Health Literacy Matter?
It is not altogether surprising that the uninsured and those with low health literacy are less likely to seek preventative care; more likely to experience poor health outcomes; and more likely to encounter higher medical costs. According to the Kaiser Family Foundation, only 1 in 3 uninsured adults said they had a preventive visit with their physician in the previous year, and uninsured adults experienced higher mortality rates than the insured. An Institute of Medicine report found a similar pattern of healthcare use for those with low health literacy, stating this group was less likely to seek preventive care. Research also found that lower health literacy in Medicaid managed care settings is connected with higher mortality. This shows that the uninsured and people lacking health literacy interact with the healthcare system in similar ways: poorly. Using the healthcare system is something people must learn. Giving someone a computer does not mean they know how to type. In the same way, connecting a person with healthcare will not alter their level of health literacy.
Old Habits Die Hard. The newly insured will continue receiving care in ways most familiar to them, which can translate to using the emergency room for non-emergencies. According to the Oregon Health Insurance Experiment, individuals who received Medicaid coverage increased their emergency room use by 40%. Asked to comment on the results, the state director of policy and programs for the National Association of Medicaid Directors alluded to the importance of promoting health literacy in the newly insured. She said, “this is not something that is unexpected” and “the key to getting inappropriate costs down for all patients is educating people about where they should go when it’s not an emergency.”
How to Address Health Literacy
Government Efforts
State initiatives, including an Illinois Emergency Room Diversion Grant are acknowledging the importance of patient education and using outreach to reduce ER use. In Illinois, hospital staff led outreach explaining the proper use of the ER and offered a 24-hour nurse triage line as an alternative. Meanwhile, Maine is targeting ER super-utilizers through community care teams that offer intensive case management including home visits and health coaching. Recognizing state efforts like that of Illinois and Maine, CMS listed patient education as a recommended component of programs targeting ER super-utilizers.
Health Professional Efforts
Beyond education on how to use their health insurance, health professionals can improve the usability of health services by reducing medical speak in patient interactions. Healthcare systems can also create plain-language pamphlets for patients to reference after leaving the doctor’s office. By speaking with patients in a relatable manner and sharing usable information, doctors better position healthcare consumers to adhere to medical recommendations.
Northwestern University’s Division of General Medicine and Geriatrics focuses on improving engagement between providers and patients and has developed plain-language materials that communicate complex health topics. For example, researchers created written information and videos available in Spanish and English that teach patients diabetes self-management. The modules use simple language and rely on pictures to communicate aspects of diabetes care, such as how the disease can impact a person’s eyes. By using these materials when interacting with diabetes patients, health professionals communicate vital aspects of care in an accessible manner, increasing the likelihood that patients adopt the healthy behaviors.
Community Health Literacy Efforts
The Be Covered Illinois campaign is promoting health literacy by generating easy-to-read written and online materials, creating short videos explaining critical concepts and utilizing community partnerships to expand the reach of their communications. By producing written fact sheets on finding the right doctor and developing web content on using your coverage Be Covered empowers the newly insured with the knowledge to navigate health insurance and health care systems more effectively. Be Covered’s Dr. Lopez video series, presented in both English and Spanish, addresses health insurance topics, chronic disease, prevention and more. Be Covered broadens the reach of their education efforts by partnering with 82 organizations in Illinois, including Illinois Health Matters, that share information and materials with their own constituencies. As part of that effort, Be Covered provides regular content for social media and shares copies of consumer friendly resources free of charge to partners.
Illinois Health Matters recognizes the importance of not only getting insurance but using insurance. The website features resources such as a Medical Cost Look Up, that allows consumers to estimate out-of-pocket costs for medical services and a resource on Immunizations and the ACA, outlining the vaccines children and adults can access for free because of healthcare reform. The website also has a tip sheet titled What to Know About Provider Networks, explaining steps consumers can take to avoid high medical costs associated with out-of-network care. These are just a few examples.
Illinois Health Matters is taking on the challenge of supporting a more health literate population, but we can’t do it alone. Join us. One great way to start: subscribe to our newsletter to stay informed and share the knowledge with your clients and coworkers. The healthcare community can achieve the vision of the Affordable Care Act, but only through the joint efforts of providers, policymakers and organizations supporting health literacy.
Providers Will Make Medicaid Care Coordination a Success
Equally important, but receiving a lot less attention are the similar challenges facing people who are trying to pick a coordinated care plan under Medicaid. Generally, having choices is a good thing, but being unarmed to make the best decision is scary. So, how does one pick?
No doubt, case managers, doctors, social workers, and community organizations hear this question all the time. When the system of health care is changing so rapidly, how are front-line professionals prepared to handle the number of questions and the confusion when they may not have a grasp on what this new system is going to look like in the first place?
Almost everyone who has Medicaid in Illinois will be required to pick a coordinated care plan. These plans are offered by managed care organizations (such as Aetna and Blue Cross) and by provider groups (such as Be Well Partners in Health) that have chosen to start innovations projects, which try new ways of managing care. Collectively, they are referred to as managed care entities, but for the sake of discussion, we will refer to them here as Medicaid health plans.
Medicaid health plans must include all of the benefits traditionally offered by Medicaid, a plan can also choose to provide more benefits than Medicaid. In addition, all plans require that members choose a primary care physician. Members with more complex care needs will also be assigned a case manager, either a nurse or social worker.
Why the Change
This shift is happening because 50% of Medicaid recipients are required by law to enter into coordinated care by 2015. But aside from the legal requirement, the move into coordinated care has a number of additional drivers, including cost containment. Medicaid costs are high, often a result of inefficiencies, uncoordinated care, and a fee-for-service reimbursement structure. The hope is that the move to coordinated care will reduce costs.As part of the move to coordinated care, the payment structure is changing. Many, but not all, Medicaid health plans will receive a capitated rate to coordinate and provide care for Medicaid members, meaning a per-member monthly reimbursement regardless of the services provided. Providers will then contract with Medicaid health plans and can negotiate their rates of reimbursement. So, Medicaid health plans receive a capitated rate, providers then negotiate reimbursement rates with the particular Medicaid health plan. Medicaid health plans are thus incentivized to control costs, because they are going to make money based upon members receiving quality care at a lower cost, rather than based upon the number of services provided.
What will all of this mean for Medicaid recipients? Each Medicaid member will receive a letter detailing health plan options available through Medicaid (many have already received them) from the Illinois Department of Healthcare and Family Services. Most will have to choose one of the plan options detailed in that letter. If they fail to choose a plan, a selection will be made for them based on their past providers, location, and previous health plan affiliation.
The choices in the letter will be based upon the Medicaid population group and where that particular member lives. For example, ACA adults have different options than Medicaid enrollees that qualified based upon disability or age; people who live in metro Chicago will choose from a different set of plans from those who live downstate. As members of these plans, there will be new rules to follow, such as using networks specific to their plan. But the plans are all Medicaid, so all of the services an individual previously had access to will remain available. And this is when the provider gets asked for help. How do they help someone choose?
The Client Enrollment Broker
Fortunately, the Illinois Department of Healthcare and Family Services has created something called the client enrollment broker. This is service that helps Medicaid members get connected to a Medicaid health plan. The client enrollment broker website (enrollhfs.illinois.gov) is where one can find information on all of the available plans, including any extra benefits that might be available, such as an allowance for over the counter products. The site has links to the website of each specific plan, where consumers can review the details of each plan.Of course, not everyone is tech savvy, or even has internet access. So the client enrollment broker is also available to assist with enrollment by phone. The client enrollment broker can be reached at 877-912-8880 Monday to Friday from 8 am to 7 pm and on Saturdays 9 am to 3 pm. The call is free.
Before speaking with the client enrollment broker, Medicaid members will want to focus on the questions to ask. They may want to write them down – much like people are advised to write down what they want to ask the doctor during an office visit. Here are some things they will need to consider when choosing a Medicaid coordinated care plan, and to discuss with the client enrollment broker if they call:
- The letter received in the mail will have a primary care provider listed. That is the provider that will be assigned to them if they do not choose a primary care provider and plan themselves. If the person has a primary care physician at present, it will be important to ask about plans with this provider in network. Otherwise, they may want to choose one before calling the client enrollment broker.
- Anyone with special healthcare needs should ask if their specialists are in-network.
- Anyone who uses medical care centers like skilled nursing facilities or hospitals should ask whether those facilities are in-network.
- The person also should consider what medications they are taking. Although Medicaid-covered drugs should be included in the formulary for every plan, there could be variations in copays or in generics vs. brand-name availability.
The client enrollment broker will ask for a social security number and the Medicaid member should have that available for the call.
This is a lot to consider, and the Medicaid population was not prepared to make these decisions alone. For someone who has never enrolled in a health plan before, or has only ever had one choice, these changes may prove overwhelming.
Provider Participation Is Essential
So it is not surprising that providers will be called upon to assist clients in making smart choices. Without provider participation, individuals may not be able to make appropriate and educated enrollment decisions that directly impact access to and continuity of care. And just as important, providers can do their best to simplify these decisions by joining networks and being knowledgeable about their own health plan network membership. Even after members are enrolled, providers can help them navigate the new and narrower networks to avoid the costs of going out of network for care.If one thing is clear it's that providers need to be engaged in the evolution of Medicaid. Without their involvement, foreign language speakers will not find providers that can speak to them, people with complex illness will not connect with physicians and specialists who have experience with those conditions, and patients with long-established doctor-patient relationships will suddenly be unable to see their doctor. Provider participation and networking is the solution to all of these issues.
But ultimately, providers need to be participating in the coordinated care system for reasons that go above and beyond making health plan choices easier for people on Medicaid. Right now, the entire Medicaid system – both traditional and expanded Medicaid – is rapidly transforming into a coordinated care system. That means that many clients or patients will be in that system, and they will be restricted to those networks. To keep their Medicaid patients, providers need to be in that system as well.
Another benefit is that billing can be simplified with Medicaid health plans. Back office billing functions – which are notoriously complicated and slow with fee-for-service Medicaid – could start to become more straightforward. In fact, Medicaid health plans should actually reimburse efficiently since they are contractually obligated to pay in a timely manner. Wouldn’t that be nice?
Care coordination is here and it is happening now. It’s time to participate. Providers can either play a part, or patients will feel the consequences. And really, so will providers.
Emily Gelber, MSW, LSW
Health Policy Analyst
Health & Disability Advocates
Learn more about Medicaid Care Coordination.
ACA: More Than Just Healthcare for People With Disabilities
For people with disabilities finding a job has always been a one-two punch. It's not just the salary and financial independence they're looking for; they also are in greater need of health benefits than say, a nondisabled 30-year old.
October 1 marks the first day that people with disabilities can finally get both needs met. Under the provisions of the Affordable Care Act, many of the barriers to private health care for persons with disabilities will disappear. Americans can now shop for benefits in the new health insurance marketplace, for coverage beginning January 1, 2014.
For the first time ever, people with disabilities cannot be denied coverage due to a pre-existing condition, denied particular services or charged more for coverage based on their health status. Many health plans have to cover certain preventive services like routine vaccinations. And the ACA limits the ability of insurers to cap annual services on patients.
The ACA undeniably changes the paradigm for working-age people with disabilities, who now do not need to choose between healthcare and a job. If an employer doesn't offer insurance, the Marketplace will, with plans starting at less than $100 a month. No longer does a person with a disability need to rely on Medicaid, the free state healthcare program for low-income people where the income requirement is so stringent that not even a full-time McJob would be allowed.
The new law also takes some of the burden off employers, too. Employers hiring people with disabilities can be assured that rates will not rise. All health insurance plans will be required to offer a standard set of benefits like hospital care and doctors' visits, as well as cover services like medication, therapy and rehabilitation services, which people with disabilities need throughout their lifetime. There will be limits on rate increases and co-pays. Small employers with fewer than 50 full-time workers can also purchase coverage through the Marketplace.
What's more, 25 states and the District of Columbia have kicked in with their own programs to provide extra coverage to workers if the benefits a company offers are too "basic" for a person's unique disability needs. These special plans wrap around private employer-based coverage.
And an optional program known as Medicaid Buy-In allows workers with a disability in 42 states and the District of Columbia to retain Medicaid coverage and pay health premiums on a sliding fee scale based on their income. Medicaid buy-in programs are geared toward higher-paid workers, for whom a salary truly trumps federal assistance.
As always, our mission at Think Beyond the Label is to increase the percentage of working-age Americas with disabilities in the workforce. The ACA will help us to be more successful at connecting qualified workers to the employers that want to hire them. No longer will a job seeker need to ask: Does my employer offer insurance? Is the plan comprehensive enough to take care of my disability? Will my health needs be better met through federal and state programs that discourage work?
The ACA makes business and economic sense, too. Less reliance on federal disability insurance programs that limit work (and cost billions of dollars a year to run). Less concerns from employers -- especially small employers -- about how to pay for coverage for a person with a disability. More opportunity for all Americans to achieve financial independence and make a significant economic contribution -- to pay for important life goals like starting a family, buying a house and sending kids to college.
Though the law may have passed under President Obama, it was Ronald Reagan who asked, "How can we love our country and not...reach out a hand when they fall, heal them when they're sick, and provide opportunity to make them self-sufficient so they will be equal in fact and not just in theory?" The ACA does just this, providing an innovative approach that will give millions of people with disabilities a chance to live the American dream, without sacrificing their critical healthcare needs.
Barbara Otto
Follow Barbara Otto on Twitter: www.twitter.com/@beyondthelabelThis post was published first on the Huffington Post blog
Primary Care Doctors Need Connections to ACA Information and to Navigators, Counselors
As the effort to promote the Health Insurance Marketplace and enroll consumers gears up, and clinics and community organizations hire, train and deploy the various “assisters” who will help patients and families get coverage, we shouldn’t ignore one of the most important touchpoints between the health care system and consumers – patient/physician interaction. Patients trust their doctors and may look to them for guidance about the Affordable Care Act (ACA). Unfortunately, many doctors haven’t been well educated about the ACA or what’s going to happen once the Marketplace is live.
The national American Academy of Pediatrics recently conducted a survey of its members and found that improvement is needed in pediatrician awareness of the Affordable Care Act (ACA). The survey, conducted in late 2012, showed that nearly half of pediatricians are vaguely or not at all familiar with key components of the ACA. Specifically, they lacked knowledge of some components that could directly benefit their practices – such as the temporary increase in payment from Medicaid to Medicare levels, and coverage of Bright Futures services with no cost-sharing for children enrolled in new insurance plans.
Pediatricians also cited low confidence in their ability to respond to parents’ questions regarding the new law. Only 5% of pediatricians reported that they are very confident in their ability, while 33% reported that they are not at all confident, with the rest somewhat or moderately confident. Clinicians such as pediatricians are not yet being asked many questions by their patients and parents, so they have not been motivated to learn their own key points or prepare their office staff to provide information. In the AAP survey, 86% of pediatricians reported that they are seldom or never asked questions concerning the ACA. Most of their knowledge to date comes from what they see in the media, so they are very much aware of aspects such as the ban on pre-existing condition exclusions, the requirements to have health insurance by 2014 or pay a fine, and the provision allowing young adults to stay on parents’ health insurance up to age 26. But once the Marketplace is up and running, and public relations campaigns about enrollment are in full swing, and assisters are everywhere, what will they need to know so they can effectively advise their patients?
Locally, two major primary care provider associations did an assessment of members which confirmed an interest in more support and information. In May 2013, the Illinois Chapter of the American Academy of Pediatrics (ICAAP) and the Illinois Academy of Family Physicians (IAFP) conducted an informal survey asking pediatricians and family physicians to estimate need for Marketplace information among patients, patient’s parents and family members, and clinic staff. Responses were received from nearly 40 unique medical practice sites employing over 500 physicians. Only 3 responded that they would not be interested in any education or services related to the Marketplace. Nearly all (85%) want information on the Marketplace to post or handout to patients, and almost as many (75%) want a counselor or assister to speak to their practice staff.
While the number of medical practices that are independent, small business is dwindling, and most staff have insurance coverage via a hospital or health system, staff may still need information for friends and family members or to make new choices if products through the Marketplace are better for their families. Only about a quarter of physicians responding expected their health system to provide information on the Marketplace for patients and staff, and most (65%) said their health system was definitely not planning to employ navigators or counselors, which may be more available in the safety net clinics than in private systems. But the need for information – even in private practices – is there! Many physicians attested to seeing their patients lose insurance due to the economy, and pediatricians regularly note that while their patients are insured via All Kids or private insurance, many of their parents or primary caregivers are not. Children also age out of All Kids or their parents’ insurance and so many young adults will seek help in securing coverage.
For the ACA roll out to work, consumers need to get quality, consistent messages about the need to enroll and how to use the health care system, no matter where they are. Targeting efforts in low income communities and in clinics that currently serve the uninsured makes sense, but the ACA effects everyone, and all primary care offices should be able to connect a patient or family who needs coverage to someone who can help them.
Scott G. Allen, MS, Executive Director
Illinois Chapter, American Academy of Pediatrics
Accountable Care Entities (ACEs): A New Coordinated Care Model in Illinois
SB 26 to be signed by the Governor into law on July 22, 2013, will expand Medicaid to over 600,000 new potential enrollees but it will also usher in a new form of coordinated care in Illinois for these new Medicaid enrollees as well as existing families on Medicaid - the Accountable Care Entity.
An Accountable Care Entity (ACE) will be a new Illinois model of an integrated delivery system. This will be the fourth model providing “care coordination services” for Medicaid clients, which now includes Managed Care Organization (MCO), Managed Care Community Network (MCCN) and Care Coordination Entity (CCE). This infographic provides a great overview of the system so far.
The ACE will have these elements:
- Will be a provider-organized network of care -- providers working together collaboratively
- Will be large enough to have impact for a population: initially children and their family members in Illinois Medicaid, at least 40,000 in Cook County, 20,000 in collar counties, 10,000 downstate
- Will have at a minimum the following types of providers: primary care, specialty care, hospitals, and behavioral healthcare; will have a governance structure that includes each type of provider and works to create a shared culture of collaboration/transformation
- Will build an infrastructure to support care management functions among the providers in the network, such as health information technology, risk assessment tools, transparent data and data analytics, communication with Medicaid members, etc.
- Will work toward a new payment structure different from the current fee-for-service: shared savings within first 18 months, partial risk after 18 months and full risk after 3 years, which means capitated payments with financial incentives for the providers within the network
The initial population assigned to ACEs will be children and family members (and likely newly eligible Medicaid clients under the Affordable Care Act.)
For more information check out the HFS Care Coordination Site
Stephanie Altman
Health & Disability Advocates
Illinois to Be Awarded Over $90 Million in Medicaid Funds for Home- and Community-Based Care
The Affordable Care Act (ACA) section 10202 establishes the Balancing Incentive Payments Program or BIP. BIP offers State Medicaid programs a financial incentive to offer home- and community-based services (HCBS) as an alternative to institutional care in nursing homes. In exchange for an increased federal matching rate (Medicaid is a State-Federal jointly paid program), States must implement 3 structural changes to their long-term services and supports (LTSS) system:
1. A No Wrong Door–Single Entry Point system (NWD/SEP)
2. Conflict-free case management services
3. A core standardized assessment instrument
In March, 2013, Illinois’ State Medicaid Agency, the Department of Healthcare and Family Services, submitted a proposal to the Centers for Medicare and Medicaid Services (CMS) to participate in BIP. On June 12, 2013, CMS announced their approval of Illinois’ BIP application, which will bring in $90.3 million of Federal matching funds into the State for Illinois projected HCBS expenditures over the next 2 years.
What Does Illinois’ Proposal Look Like?
Illinois’ BIP proposal is the most comprehensive overview of the State’s various LTSS programs: from aging, to development disabilities, to physical disabilities, to mental health, to substance abuse—Illinois’ BIP proposal covers it all. For anyone who wants a crash course on what Illinois is doing in the area of LTSS balancing—the development of a LTSS system that is more home- and community-focused than institutional focused—the BIP application is a great place to start.
In reading through the BIP proposal, you will see that Illinois is planning to integrate LTSS through collaboration across governmental department silos. The BIP operating agency will be the State Medicaid Agency: the Illinois Department of Healthcare and Family Services (HFS). HFS is already working in partnership with its sister agencies on implementing BIP:
- The Illinois Department on Aging (DoA)
- The Illinois Department of Human Services (DHS)
- Division of Developmental Disabilities (DHS/DDD)
- Division of Mental Health (DHS/DMH)
- Division of Rehabilitation Services (DHS/DRS) Division of Alcoholism and Substance Abuse (DHS/DASA)
Further, Illinois’ BIP goals will build off the existing work that Illinois is doing to balance LTSS in favor of HCBS. Existing LTSS balancing projects in Illinois include:
- the closing of State institutions,
- implementation of 3 Olmstead lawsuits [Williams, Ligas and Colbert],
- the Money Follows the Person Program,
- expansion of coordinated/managed care models,
- development of the state-wide community-based Aging and Disability Resource Center (ADRC) system, and
- ongoing provision of HCBS through Medicaid 1915 (c) waivers, of which Illinois currently operates 9 waivers.
The work described in the BIP application details how Illinois will implement the 3 structural requirements of BIP: a no wrong door–single entry point system (NWD/SEP), conflict-free case management services, and core standardized assessment instrument. These 3 areas are described below briefly. It is important to note that currently Illinois has separate systems for each sub-population served in its LTSS programs: aging, physical disability, mental health, substance abuse, development disability. BIP provides Illinois with the opportunity to coordinate across the population groups from the community and consumer level, all the way up to the State government level.
1. Illinois’ No Wrong Door–Single Entry Point system (NWD/SEP)
Entry points for LTSS are not currently coordinated across aging and disability populations. Current access points include: DHS local offices, Aging and Disability Resource Centers (ADRCs), Area Agencies on Aging (AAAs), Division of Rehabilitation Services local offices, Pre-Admission Screening agencies that serve persons with intellectual/developmental disabilities, community mental health centers and regional mental health points of contact, and State agency websites.
The ADRC network offers a starting place to coordinate across all of these different access points. Under the leadership of Illinois Department on Aging, the vision for the ADRC system is “a highly visible and trusted resource for all persons regardless of age, income and disability, to access a coordinated point of entry to public long-term support programs and benefits, and to obtain information on the full range of long-term support options”. [See page 31 of the BIP proposal].
Illinois’ ADRC system is already in development with 7 ADRCs up-and-running across the state—through AAAs in collaboration with disability organizations. It is anticipated that by September 2016, all of Illinois’ 13 Planning-and-Service-Areas (PSAs) will have designated ADRCs through leadership from Illinois’ AAAs. ADRC entities also currently include Care Coordination Units, Community Care Program providers, Centers for Independent Living, and DoA’s Senior Help Line (a State-wide toll-free phone number).
The NWD/SEP system will allow for individuals to receive a level 1 screen to determine which LTSS an individual should be assessed for. Access to this level 1 screen will be available online through a coordinated network of ADRC partners.
2. Illinois’ Conflict-Free Case Management Services
Illinois has different case management systems for each population group served. To ensure conflict-free case management, per Federal guidance, Illinois will work to separate the determination of eligibility process from case management, and from the direct delivery of services.
In the BIP proposal, Illinois describes the current developmental disability and physical disability processes to be conflict-free. However, more work needs to be done in the area of mental health/substance abuse and aging to ensure conflict-free case management [see pages 23-24 of the BIP proposal].
The expansion of managed care models in Illinois will help to promote conflict-free case management. With the help of BIP funds, Illinois will also continue to work with CMS to identify potential conflicts of interest and to develop the proper firewalls between eligibility determination, case management and service delivery.
3. Illinois’ Core Standardized Assessment Instrument
Over the past year, Illinois human service agencies have collaborated with Navigant consulting to review Illinois’ current assessment tools and methodology (each population currently has their own assessment tool). With Navigant, Illinois will develop a uniform assessment tool (UAT) for access to LTSS. Recently, HFS released a Request for Information related to the development of the UAT as the State seeks out vendors who can integrate and coordinate across populations and State departments.
A UAT will allow Illinois’ to develop a more consumer-centered LTSS system. Many individuals with LTSS needs require complex care and fall into more than one category across the current Medicaid HCBS waiver system. This means that consumers with mental health needs who are also 60 years or older must access two separate programs to have their needs meet: one in mental health and the other in aging. This makes it very challenging for consumers, and cumbersome and redundant for State agencies. BIP is intended to fix this, to ease access to LTSS in a more timely and appropriate way.
Further, Illinois is also replacing the 30-year old COBOL-based system that is currently in use to determine eligibility for: Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly ‘food stamps’), Temporary Assistance for Needy Families program (TANF), and the new Health Benefits Exchange, or Marketplace, required by the ACA. The new Integrated Eligibility System (IES) is branded as Application for Benefits Eligibility, or ABE.
What all of this means for professionals and consumers is that Illinois is moving towards a system that will significantly streamline the determination of eligibility process for a variety of different programs, including LTSS. Part of this systemic upgrade includes ensuring better Information Technology (IT) integration and easier access to data about these publicly funded programs across population types.
Stay Tuned as Illinois Continues to Balancing LTSS in Favor of HCBS
As Illinois implements BIP and its other LTSS balancing programs, the State’s goal is to develop a new HCBS infrastructure that is consumer driven and easy to access and navigate. We look forward to reporting back as consumers across the State find it easier to live and receive care in their homes and communities.
Please let me know if you have questions, comments or responses to this blog post. You can reach me at: 312.372.4292 or kpavle@hmprg.org.
Kristen Pavle
Associate Director, Center for Long-Term Care Reform
Health & Medicine Policy Research Group
Will Illinois Have Enough Family Physicians Beyond 2014?
Do we have enough physicians to care for newly insured patients seeking care starting Jan. 1? Some will be covered by Medicaid; some gain coverage through the insurance marketplace; and others turning 65 join the ranks of Medicare. The Illinois Academy of Family Physicians believes that we are ready for 2014 – but are not prepared for future demand for primary care.
Illinois currently has the capacity to care for more than 5.3 million Medicaid patients, with more than 5,000 primary-care providers participating in team-based medical homes. When patients have a regular primary-care physician, they get the care they need to avoid costly emergency room visits and hospitalizations. Connecting new Medicaid patients with a family physician ensures they get the right care at the right time in the community setting, at a much lower cost. Otherwise uncontrolled chronic illnesses can develop into costly – and preventable – hospitalizations, which drives up medical costs for everyone.
Illinois has 11 medical school campuses. This year, only 9 percent of 1,089 doctors graduating from those medical colleges chose family medicine, according to IAFP data. And only one-third of that 9 percent — 35 people — will do their residency training in Illinois; the rest will leave for other states. Family physicians are the only physicians trained to care for all ages, both male and female.
Illinois should worry about the future of our state's primary-care physician workforce. Simply stated, too many physicians trained here choose to work in other states, and Illinois is not training enough primary-care physicians.
A NATIONAL PROBLEM, TOO
According to the American Association of Medical Colleges workforce data book, Illinois ranks 20th in the nation with 95 primary care physicians per 100,000 residents. As a nation, we are facing a staggering shortage of primary care physicians. So being in the middle of the pack should not be interpreted as a positive sign.
A 2010 study led by family physician Russell Robertson (now dean of Chicago Medical School) examined new physicians' plans for practice and the reasons for their choices. Almost one-half of graduating Illinois residents and fellows leave the state to practice elsewhere. While the primary reason for do so is for family, the medical liability climate is a major consideration for those who leave Illinois to practice.
How can we turn the tide? Medical schools need admission policies favoring students willing to practice in Illinois. We also must address medical school debt that keeps many from entering primary care. Those physicians should get loan repayment or loan forgiveness incentives to practice in areas in need of primary-care physicians. As well, the income gap between primary-care and specialty physicians must be narrowed. Medicare and Medicaid must take the lead and pay primary-care physicians in accordance with the quality care and coordination services they provide, and private insurers must support primary care.
Making primary-care practice a priority ensures that every Illinoisan entering the health care system has a medical home to care for them. A future without enough family physicians will leave patients without a medical home and on the doorsteps of emergency rooms instead.
The University of Chicago Medicine, along with other health care providers, is moving ahead with changes under health care reform following the U.S. Supreme Court’s decision in June upholding the Patient Safety and Affordable Care Act of 2010. Not since 1965, when the Medicare and Medicaid programs became law, has the nation faced a more monumental shift in health care.