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Warning issued over putting medically fragile children in Medicaid managed care

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Illinois

Recent questions over Gov. Bruce Rauner’s Medicaid managed care overhaul have mostly focused on the program’s rising costs and secretive contracting processes. Much less attention has been paid to the potential human impact of the program, which will force more than 500,000 people to change their insurance plans, and touch roughly one quarter of all Illinois residents. While the goal of the program is to improve health and reduce costs, there will, in fact, be plenty of people harmed by the transition.

Among the most at-risk are children with chronic, severe medical conditions, also known as children who are medically fragile. For children who are medically fragile, managed care will be devastating. Cutting services and benefits is the only way for managed care organizations to reduce costs for this population.

Until her death in 2014, my daughter Karuna participated in a program called the Medically Fragile, Technology Dependent Medicaid Waiver, which allows children requiring ventilators, tracheostomies or central intravenous lines to live at home, thanks to home nursing provided by Illinois Medicaid. Traditionally, states have recognized that children like Karuna aren’t a good fit for managed care, because their needs are too specialized and extraordinary. Unfortunately, the Rauner administration chose to ignore this precedent, and plans on moving these children into managed care starting in July.

The few states that have moved individuals who are medically fragile into managed care have experienced unanticipated negative outcomes, including loss of home nursing care; elimination of therapy services, medication and service denials; hospitalizations; emergency visits; and even deaths. In Illinois, the situation would likely be even worse, since managed care organization contracts have no provisions that would ensure children who are medically fragile maintain access to their medical equipment suppliers, home nurses and pediatric subspecialists. These omissions will put the lives of children like Karuna at risk, and will also inevitably cost taxpayers, who will be forced to pay for hospitalizations when children can’t get the care they need at home.

* Related…

* Health Insurer Centene Is Sued Over Lack of Medical Coverage: People signed up for insurance and they “ discovered there were no doctors,” said Seth Lesser, a partner at the law firm of Klafter Olsen & Lesser who is representing some of the policyholders.

posted by Rich Miller
Wednesday, Jan 17, 18 @ 12:07 pm

Comments

Can we all agree that medically fragile children shouldn’t be left to the whims of the bean counters?

Especially bean counters looking to get fat on contracts whose estimates shot up by $20B in a week without any explanation?

Maybe there are some savings in that mysterious $20B. Let’s take a hard look, shall we?

Comment by wordslinger Wednesday, Jan 17, 18 @ 12:31 pm
==Centene, a large for-profit health insurance company==

And there’s the rub. When you are a for profit entity your concern isn’t with the patient. It’s with making money. It’s a sad commentary on our healthcare system.

Comment by Demoralized Wednesday, Jan 17, 18 @ 12:47 pm
Question to the Post- Could the ILGA place restrictions on Rauner’s plan so families that have children who are considered medically fragile can contest a move into managed care? And, if this can be done, it should be addressed in the upcoming sessions ASAP. Hearings could start now to prepare for legislation.

Comment by Anon221 Wednesday, Jan 17, 18 @ 12:47 pm
This is scary as hell. I can’t imagine what parents are going through. “I am not in charge” and “these things happen” doesn’t cut it.

Fix this now. Let’s Not accept bureaucratic assurances “our networks are adequate”. Things can go south for these families in a matter of hours.

Comment by Langhorne Wednesday, Jan 17, 18 @ 1:06 pm
===Can we all agree that medically fragile children shouldn’t be left to the whims of the bean counters?===

Are there no workhouses?

Comment by 47th Ward Wednesday, Jan 17, 18 @ 1:11 pm
“People signed up for insurance and they “discovered there were no doctors”

You want a doctor?! I thought you just wanted insurance?

Comment by City Zen Wednesday, Jan 17, 18 @ 1:15 pm
In a somewhat related topic, other states have also not been able to demonstrate success by turning over long-term care case management to managed care companies for their adult citizens with intellectual and/or developmental disabilities. Illinois has postponed this phase of managed care, called Phase Three, for several years. It should be postponed indefinitely.

Comment by Dome Gnome Wednesday, Jan 17, 18 @ 1:54 pm
== Question to the Post- Could the ILGA place restrictions on Rauner’s plan so families that have children who are considered medically fragile can contest a move into managed care? And, if this can be done, it should be addressed in the upcoming sessions ASAP. Hearings could start now to prepare for legislation.==

That is what Greg Harris and the House Dems tried to do and have been trying to accomplish. Harris has been talking about these kids for months but it’s gotten lost. The department did this procurement despite concerns expressed by the General Assembly.

Comment by FCCMJM Wednesday, Jan 17, 18 @ 1:55 pm
Thanks FCCMJM. It’s time for the Lost to be Found. Has Harris filed any bills on this?

Comment by Anon221 Wednesday, Jan 17, 18 @ 2:11 pm
Rep. Harris is doing his part on this issue. What’s amazing is that DCFS and HFS haven’t done any legwork at all, to protect these kids and to push back against IlliniCare. They could solve this pretty quick if they wanted to.

Comment by Anonymous Wednesday, Jan 17, 18 @ 2:38 pm
“What’s amazing is that DCFS and HFS haven’t done any legwork at all…”

No, not really. Why should the heads of these agencies, under Rauner’s direction, buck Rauner? They couldn’t even come up with budget cuts when asked at the budget hearings (and I do realize that some of the heads have changed since then). If the Agencies won’t step in to protect the people they are supposed to protect, then a legislative change needs to be done. If that isn’t done, then I am sure we will be seeing some deaths and lawsuits by families. Now, when that happens, is Rauner going to go on another “field trip” to assure us it’s all under control??? Or will he be content with a, “These things happen,” message to comfort the parents???

Comment by Anon221 Wednesday, Jan 17, 18 @ 2:54 pm
Managed care for individuals with intellectual disabilities who live in long term care is to begin in 2018. I am not sure how any long term care can benefit from being in managed care.

Comment by Anna Wednesday, Jan 17, 18 @ 3:11 pm
It’s medical services for individuals with intellectual/developmental disabilities (/IDD) that is now under managed care.

Dome Gnome is correct in that long term residential and day support for people with I/DD needs to be exempted from managed care. These kinds of disabilities are chronic and life-long and cannot be “cured”.

However, given the secrecy under which the medical managed care contracts were awarded, don’t be surprised if a long-term services contract(phase 3) suddenly appears.

Comment by BobO Wednesday, Jan 17, 18 @ 4:02 pm
BobO, not sure what you are talking about here “It’s medical services for individuals with intellectual/developmental disabilities (/IDD) that is now under managed care”.
The 3 Medicaid DD waivers populations are not in Managed Care, nor is there a timeline for them to be enrolled in managed care currently. Not all people with DD problems are in the waivers but I think the majority are, don’t quote me on that.

Comment by Perrid Wednesday, Jan 17, 18 @ 4:25 pm
Medicaid managed care is coming for people in DMH funded programs. It is supposedly far off for the I/DD population, if ever. It has existed in some larger Illinois counties for some time. On April 1 all other counties will be enrolled in one of 5 MCOs. Cook County will have 2 additional MCOs. So far there has been one meeting for about 100 potential providers. That’s it. No idea how many medical providers have signed up. Medicaid reimbursement is extremely thin to providers even as it is growing by volume.

Iowa started Medicaid managed care over a year ago. First year resulted in $500 million loss for the three MCOs. The largest one dropped out and the two others could not handle the volume. Response from Iowa state gov: ‘It’s going pretty well’. Why? Because state dollars spent are down. Why? MCOs say ‘No’ a lot. Quality of services: according to major Iowa newspapers, not so good. Many long standing providers lost their best staff to MCOs because they pay much better. According to major Iowa newspapers, there is a growing list of lawsuits by people who had services cut under managed care.

Comment by zatoichi Wednesday, Jan 17, 18 @ 6:19 pm
This whole $63B series of contracts stinks to high heaven and needs a thorough airing in the GA and by the media.

The administration’s cost estimate went from $40B one day to $63B a week later when they awarded the contracts. That’s off by more than 50%.

I would think even “fiscally conservative Republicans” of 2018 vintage would want to know how the heck that happened.

Comment by wordslinger Wednesday, Jan 17, 18 @ 7:30 pm