Taking care of Sandra Tobar’s 14-month-old Camillah is often more involved than feeding her or changing her diaper.
Camillah has constant doctor appointments for a variety of issues caused by a rare condition that delays growth and development. Emergencies have sent Camillah to the hospital 12 times since she was born, Tobar said.
“I try my best,” said the 30-year-old Tobar, who lives in the Avondale neighborhood. But she admits it can be stressful because she stays at home to also take care of her 12-year-old son while her husband works.
So when Camillah’s hospital, Ann & Robert H. Lurie Children’s Hospital of Chicago, told her about a new Medicaid program for children with special health care needs that includes a nurse to help her coordinate care for Camillah, she didn’t hesitate to apply.
“That is going to help me take better care of her, having that extra eye,” Tobar said. She also hopes having a nurse for Camillah will minimize her emergency trips to the hospital.
Lurie Children’s Hospital is seeking to make these types of helpers available to at least 5,000 Medicaid children who have moderate to severe diagnoses such as cystic fibrosis or spina bifida in order to make sure they’re getting the care they need.
It’s part of a larger change to how Illinois Medicaid is being delivered.
The state is shifting at least 50 percent of Medicaid’s 3 million people into care coordination programs by Jan. 1, 2015. The state started enrolling most of these people in July, though some Medicaid patients were moved to these programs as early as 2011.
What a care coordination program will look like for these people depends on which type of “managed care entities” they enroll in; Illinois has five different types.
The gist behind all five is to give each Medicaid enrollee a health plan and a primary care physician. Each health plan would have a care coordination team to ensure enrollees are getting the care they need, while everyone is in communication about those enrollees.
“This is what other states did, some of them many years ago,” Illinois Department of Healthcare and Family Services Director Julie Hamos said. “We are testing innovations in Illinois.”
The goal is to make it easier for people to manage their ailments or needs and, in the process, reduce the cost for their health care.
Medicaid, the state-federal health program for low-income people, is one of the costliest expenses for cash-strapped Illinois.
Medicaid traditionally reimburses providers for each service it performs, a system that rewards volume instead of quality. The shift to coordinated care means hospitals, insurers and other providers will instead receive a fixed monthly payment for each Medicaid patient, meaning the healthier a Medicaid patient is, the more money health care providers make.
Barbara Otto, CEO of Health & Disability Advocates, said, “In and of itself, there is nothing wrong with managed care, especially if it is . . . focused on coordinating care to improve access and quality of care.”
Yet, she noted that it might take time to see cost savings.
“Even the best-run Medicaid managed care programs in other states do not see cost savings in the first five years,” she said.
Four main groups are making the shift: seniors and persons with disabilities; children and their families; children with special needs; and those adults who are newly eligible for Medicaid because of the Affordable Care Act.
These individuals will come from Cook County and the collar counties, Rockford, central Illinois, Metro East area of St. Louis and the Quad Cities.
“If you had somebody, for instance, in Decatur with spina bifida, they would be given a choice of a very specific managed care organization, where if you had somebody in Chicago who was a 25-year-old single female, she would have very different choices,” said Molly Siegel, care coordination entity program manager at Healthcare and Family Services Department.
Managed care entities have gone or are going live at different times depending on when they received clearance from HFS.
Medicaid enrollees who receive a letter have 60 days to select a health plan. They will receive another letter in 30 days if they don’t respond. Then, after another 30 days, they will be auto-enrolled in a plan.
Medicaid clients should contact Illinois Client Enrollment Services at (877) 912-8880, TTY at (866) 565-8576 or go online to the Illinois Department of Healthcare and Family Services for more information.