by Dr. Edward Pont
Because of the controversies surrounding expected cuts to Illinois’ Medicaid program during this year’s legislative session, Illinois Issues is publishing this guest column by Dr. Edward Pont, a pediatrician who is a member of Gov. Pat Quinn’s Medicaid Advisory Committee. The magazine’s publication of this column does not indicate either endorsement or rejection of Dr. Pont’s ideas. Executive Editor Dana Heupel’s Editor’s Note column will return in the July-August issue.
This seems to be the one thing everyone, irrespective of political bent, can agree on with regard to our state’s Medicaid program. Medicaid is hopelessly broken, and unless we repair it, the program will topple under the weight of all the care it delivers to Illinois’ neediest citizens. It is a colossus, providing health care to close to 3 million Illinois residents, including one of every three children. It must be stopped, or at least reformed, lest it consume the entire state budget.
On the contrary, Medicaid is one our state’s most important assets. During the most recent fiscal year, it brought close to $10 billion federal dollars into Illinois, more than any other state program by far.
Contrary to the generally held view of government bureaucrats, its veteran staff view health care providers like myself as partners to work with to strengthen the program. And in my office, I see the benefits of the program every day. Even as their economic situations become increasingly tenuous, most parents retain the security of knowing their children will receive health care thanks to Medicaid.
As with any large program, public or private, there are problems with Illinois Medicaid, but fiscal profligacy is not one of them. Illinois consistently ranks near the bottom in terms of Medicaid reimbursement, and it compounds this by routinely delaying payments.
According to the Department of Healthcare and Family Services’ most recent annual report, per capita spending on Medicaid recipients has remained relatively constant (and well below commercial benchmarks).
What has changed is the number of people Medicaid serves.
Far from dysfunction, this is what a countercyclical program is supposed to do in the wake of the greatest economic turmoil since the Depression.
In fact, a recent study by the Robert Graham Center concluded that the current model the state utilizes to administer the program, the primary care case management system (PCCM), has saved Illinois $2 billion over its lifetime.
Medicaid used to simply pay medical bills without regards to quality. Under the PCCM, patients are assigned to a doctor who takes responsibility for their care. Working with a disease management company, the PCCM achieved its savings because more people were seen in doctors’ offices, and as a result needed the emergency room and hospital less. Put another way, were it not for the PCCM, as bad as things are now, they could have been significantly worse. Quality measurements have also risen under the PCCM model.
One would think this success would have cemented the PCCM model in the minds of both the Quinn administration and the General Assembly. However, the 2010 Medicaid reform law specifically excluded the PCCM from participating in the state’s reform effort. Barring anything unforeseen, by 2015 the PCCM will likely be relegated to our state’s less populous areas. We’re well on our way to replacing it with a patchwork of Medicaid managed care organizations (MCOs). Change demands doing something different, and advocates correctly point out that Illinois is one of only a few states where Medicaid MCOs have not caught on.
Many legislators and policymakers equate MCOs with cost savings. But a recent national study debunked this myth: In the aggregate, MCOs pay doctors and hospitals less, but insurance companies have kept the savings for themselves, so the effect on state budgets has been negligible, according to the National Bureau of Economic Research. There is no reason to think we’ll have a different outcome in Illinois, and the disruption to patient care will likely be significant. In testimony for the Illinois House and Senate Special Committees on Medicaid Reform, Dr. Margaret Kirkegaard, medical director for Illinois Health Connect Illinois Primary Care Case Management Program, said that when given a choice, Illinois Medicaid patients choose an MCO only 15 percent of the time.
This will be unfortunate in human terms, but the fiscal impact could be equally profound. Organizations that see a large volume of Medicaid patients will play ball with any insurer, but two-thirds of the state’s medical homes see fewer than 250 Medicaid patients, according to Kirkegaard. These physicians will likely reconsider their participation in Medicaid, especially if they are faced with several MCOs — each with their own referral regulations, claims forms and preauthorization policies — rather than a unified PCCM program that is widely accepted in all areas of the state. Patients suddenly finding themselves without a medical home will go to the emergency room, where illness is more severe and care is necessarily more expensive.
So what can be done?
First and foremost, state government should consider allowing the PCCM to participate in Medicaid reform. With its proven track record of patient care and cost savings, it can make a solid contribution to resolving Medicaid’s long-term budget problems.
Additionally, legislators and policymakers need to realize that the central issue with Medicaid is not one of cost but rather of revenue. No matter which path Medicaid reform ultimately takes, new funding sources will have to be found.
The Illinois citizens who rely on Medicaid to stay healthy deserve nothing less.
Dr. Edward Pont, a community pediatrician in Chicago’s western suburbs, is the current Government Affairs Chair for the Illinois Chapter of the American Academy of Pediatrics, as well as Quinn’s Medicaid Advisory Committee.
Illinois Issues, June 2012