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Blog Posts from 2013

Welcome to the blog for Health & Medicine. We're a 33-year old 501c3 nonprofit that operates as an independent, freestanding center driven by a singular mission: formulating health policy, advocacy and health systems to enhance the health of the public.


Oct 29, 2013 Written By: Wesley Epplin

Health and Medicine Hosts Community Health Centers and Managed Care Organizations Forum

The following post provides a brief summary of the proceedings and notes from a recent HMPRG forum focused on community health centers (CHCs) working with managed care organizations (MCOs).

Health and Medicine Policy Research Group hosted a forum on October 1, 2013 focused on providing tools to help community health centers (CHCs) contract with managed care organizations (MCOs).  Navigating Relationships in an Evolving Healthcare Environment: Community Health Centers and Managed Care Organizations Forum brought together people from CHCs, health departments, hospitals, and other health professionals who work with or are planning to work with MCOs.  The following provides a snapshot of the three main forum sessions.  Some of the notes are taken verbatim from the presenters’ slides and others are in an abbreviated form.  The information and ideas that follow are those of the different forum presenters.

Session 1: Dr. Art Jones, Principal, Health Management Associates: Provided overview of the managed care environment.

After providing some of his background in working both at a CHC and with managed care, Dr. Art Jones reminded the audience of the triple aim of: improving population health, controlling costs, and improving individual care experience.   Jones also pointed out that with the ACA being implemented, two inter-dependent objectives are being attempted: 1) make adequate health insurance coverage more available and affordable; and 2) reform delivery and payment systems to provide better care in a more cost-efficient manner.  Managed care attempts to address this second objective.

So, how do FQHCs work to improve outcomes and change the payment system in tandem?  They can use a progression with true partnership to transition from FFS to managed care payment.  With managed care, FQHCs move slowly to take on more financial risk and with it, greater accountability.  Negotiating with MCOs, they receive money for care coordination.  They may take on total financial risk for some services.  For example, being responsible for emergency department (ED) visits, an FQHC might move to being open at night, having shorter wait times for appointments, and having nurse triage.  This may lead to increasing revenue and savings, because of reductions in ED visits.

Dr. Jones listed some contract pitfalls and advice:
  • Non-solicitation clauses: These say that you can’t contact your members if you stop working with their insurer.  Don’t sign this.
  • Termination without cause clauses: Don’t sign this.
  • Transfer of members before cure period expires for breach of contract: Usually 60 days to cure problems, after which insurer can break contract and transfer members.  Don’t sign the clause that says they can transfer before cure period.
  • Indemnification, defending, and hold harmless clauses: Don’t sign contract saying you’ll indemnify them; take that clause out.
  • Unilateral contract amendments: Don’t sign this.  The MCO should have to check in with the health center to make any amendments.
  • Failure to review the provider manual: Look at this ahead of the contract and make sure it is something you can live with.
  • Ability to terminate contract immediately for MCO insolvency or non-payment: Need clause saying that you can terminate contract, or else in some circumstances the CHC may have to provide services for 90 days without getting paid.
  • Review all of these with an expert.
Session 2: The forum also included two leaders from CHCs: Bob Urso, MS, MHA, BSN, President and CEO, PCC Community Wellness Center, and Lee Francis, MD, MPH, President and CEO, Erie Family Health Center.

Here are contracting recommendations and considerations from the CHC representatives:
  • If new to managed care, consider attempting to form one model contract with one MCO, test it out, work out kinks, and then be able to judge future contracts against the initial contract
  • Consider different payment models, including: FFS; PCP vs. Full/Partial risk; P4P; SSF; wrap payment; and care management fee
  • Importance of addressing the triple aim of improving patient care, improving the health of patient populations and communities, and lowering the per capita cost of providing healthcare
  • Need integrated delivery system, in which we work toward becoming accountable care entities, involving hospitals, specialists, PCPs, behavioral health, and other providers.
  • Research any given MCO in preparation for contracting, including: assessing market share, service area, stability, solvency, and reputation.  Also, investigate who owns the MCO, is it for-profit or non-profit?
Session 3:  Two representatives from MCOs provided their perspective on navigating these relationships: Sanjoy Musunuri, CEO, AETNA Better Health and Matthew Collins, COO, Cigna-HealthSpring.

Here are considerations and recommendations from the MCOs’ perspective:
  • Requirements include: access and availability, including ADA compliance; licensure and credentialing; meeting of administrative obligations; hospital/NH privileges; and rates
  • CHC partner attributes: willingness to serve the populations; cultural competence; capability to be a medical home; focus on quality; delivery system innovations
  • Contracting needs include having engaged providers with a strong presence in the community
  • Also, looking for quality provider partners: government is working on definition of quality, holding MCOs accountable for quality results; MCOs are then holding providers accountable
  • MCOs want to work with CHCs who know the basic premises of managed care; important for providers to understand how managed care works
Each session ended with Q and A with the audience.  For more extensive notes and to review the slides from each presenter, click here.

Aug 30, 2013 Written By: Kristen Pavle

Transition to Medicaid Managed Care in Illinois

In July of 2013, Health & Medicine Policy Research Group developed a report: “The Transition to Medicaid Managed Care in Illinois: An Opportunity for Long-Term Services and Supports Systems Change.” The Executive Summary is posted here as a blog post explaining Illinois’ recent and important health system reform initiative of transitioning from a Medicaid system that is primarily fee-for-service to a coordinated or managed care system.  You can access the full report by visiting Health & Medicine Policy Research Group’s website or click the title of the report above.

Executive Summary
In January 2011, the 96th Illinois’ General Assembly passed legislation mandating 50% of the Medicaid population to be covered in a risk-based care coordination program, or managed care program.  In Illinois, managed care is an approach to catalyze health systems that provide services to the Medicaid population to change their practices in alignment with the Institute for Healthcare Improvement’s triple aim  of:
•    Improving care on the consumer level (e.g. quality and satisfaction)
•    Improving population health
•    Reducing the cost of health care
Illinois’ State Medicaid Agency (SMA), the Department of Healthcare and Family Services (HFS), is providing leadership for the transition from a primarily fee-for-service (FFS) Medicaid system to a new managed care system.  Under HFS’ leadership, Illinois’ Medicaid managed care (MMC) model is based on an ‘all-in’ approach where all Medicaid services will be integrated through managed care organizations (MCOs).  The ‘all-in’ approach is a best practice within MMC and a good foundation for the development of Illinois’ MMC system.

Further, the ‘all-in’ approach includes long-term services and supports (LTSS) for older adults and persons with disabilities, both institutional (i.e., nursing facility) and home- and community-based care.  HFS is working in partnership with the Department on Aging (DOA) and the Department of Human Service (DHS) to ensure quality and to provide oversight of LTSS for older adults and persons with disabilities in the new MMC system.  The choice to include LTSS gives Illinois the opportunity to build on the mostly medical model of the triple aim and include important social services that address the social determinants of health.

This report was developed in partnership between Health & Medicine Policy Research Group and Illinois’ Older Adult Services Advisory Committee.  The report provides an overview of what the transition from a Medicaid FFS to a managed care system will entail for stakeholders in Illinois, paying particular attention to LTSS stakeholders.  Six stakeholder groups are identified to include:
1.    Consumers
2.    Advocates
3.    Providers (including informal family caregivers)
4.    Payers (including state government agencies)
5.    Managed care organizations
6.    Researchers/academics

The transition to an MMC system is an almost immeasurable challenge because it represents not only a significant change from how stakeholders have worked together for several decades in the FFS system but also how they will work together in the future.  The inclusion of LTSS in the MMC system is particularly challenging because of the inexperience of states across the country in implementing ‘all-in’ managed care models.  Best practices, standardization, and demonstrated outcomes of these models are only now beginning to emerge.

This report provides a synthesis of a literature review on the topic of MMC and LTSS, and findings from interviews with key informants from Illinois and from several experienced MMC experts. Opportunities for Illinois to take advantage of these findings in order to ensure a smooth transition to an MMC system are provided at the end of the report.  The opportunities are summarized below and formatted in a way to address the 4 greatest challenges identified for Illinois as it transitions to an MMC system

Challenge: Effective Stakeholder Engagement
Stakeholders working in silos will limit Illinois’ capacity to achieve an integrated MMC system that improves health care, improves population health, reduces costs and addresses social determinants of health. In regards to LTSS, without formal channels for LTSS non-governmental stakeholder engagement, LTSS consumers are at risk for poor health care and poor health outcomes.  

In order to integrate care in the new MMC system Illinois should go beyond innovation within silos and look to creating accountable partnerships across silos. Although State departments must certainly take on a central leadership role in the transition to MMC, meaningful stakeholder engagement is essential through all phases of the transition to the MMC system. The states interviewed for this project and the literature strongly support formal development of stakeholder engagement processes (page 34-36).

Opportunities for OASAC Engagement in Illinois:
1.    Increase State government transparency
•    Develop a user-friendly website that includes comprehensive information about the Medicaid Managed Care (MMC) system.
•    Share State department organizational charts that detail which people/agents are responsible for MMC activities.

2.    The Older Adult Services Advisory Committee (OASAC) should create a long-term services and support (LTSS) stakeholder engagement workgroup.  While the workgroup should focus on LTSS stakeholder engagement, the model development should have applicability and utility for all stakeholder groups.
3.    OASAC should review its membership structure in response to the transition to an MMC system and an ADRC system.  

4.    OASAC should immediately submit to the Illinois Department of Healthcare and Family Services (HFS) the MMC LTSS quality measures research conducted in conjunction with this report.  
•    In collaboration with LTSS stakeholders, HFS should identify additional priority LTSS quality measures for the Illinois MMC system.

Challenge: Adequate State Government MMC Expertise
MMC is not a typical Medicaid program in that a large number of beneficiaries are enrolled into one integrated program, therefore requiring a significant amount of money to be paid to one entity: an MCO. This represents a dramatic shift in how the Medicaid program has been historically structured, where beneficiaries were spread among many providers through many separate programs and service line FFS reimbursements (page 18).

As a result, the State must be prepared to provide a level of oversight greater than in the FFS system (pages 18-19). Therefore, Illinois’ state agencies must be knowledgeable about managed care in order to provide appropriate oversight of MCOs.  For LTSS, this requires multiple State agencies to have trained staff and appropriate organizational structures.  These agencies include DOA, HFS, and DHS (pages 19-23).

Opportunities to develop adequate state government MMC expertise in Illinois:
Illinois’ governmental agencies should train and recruit specific, qualified MMC staff with expertise to provide oversight and monitoring in the MMC system. Illinois’ governmental agencies involved with MMC should:
1.    Assess their current staff to determine where gaps in staff expertise exist and where to target training or new staff recruitment.

2.    Collaborate with local academic institution(s) and managed care organizations (MCOs) to develop a managed care training curriculum for State government employees.  

3.    Assess their current organizational structures to determine if the current structures will allow for sufficient MMC oversight.

4.    Evaluate the existing MMC LTSS oversight structure that is currently the responsibility of three agencies: Department on Aging (DOA), HFS, and Department of Human Services (DHS).  
•    Clearly articulated roles and responsibilities should be developed between agencies through Memorandums of Understanding (MOUs) that clearly define MMC LTSS oversight structure.

Challenge: Aging and Disability Resource Center (ADRC) Integration with MMC
Stakeholders working in silos risk losing the opportunity to better integrate medical and social care and to rebalance LTSS in favor of HCBS.  HFS, as the State Medicaid Agency, is ultimately responsible for the MMC system and developing a broad coordination effort across systems to assure there is no wrong door for MMC consumers.

DOA is providing leadership in the development of an ADRC system in partnership with the aging and disability communities to ensure no wrong door for LTSS consumers (pages 40-42). As DOA, DHS, and HFS develop the work plan for the State Balancing Incentive Payment Program (page 41), the ADRC network will become an important entry portal for the MMC system.

ADRCs are a coordinated-point-of-entry or no-wrong-door system of access to LTSS and include aging and disability network stakeholders.  ADRCs have expertise in community-based social services that include Medicaid funded services, but also include other funded services like those provided through the Older Americans Act.  

Under DOA’s leadership, ADRCs have the expertise and experience to develop a strong community-based LTSS network. Through deliberate and formal partnerships between HFS and DOA and engagement of ADRC stakeholders, the MMC and ADRC systems can better integrate medical and social care for individuals who require LTSS, and promote the balancing of LTSS in favor of home- and community-based care (pages 41-42).

Opportunities for ADRC integration with MMC in Illinois:
1.    DOA should develop a strategic vision for its ADRC network that clearly articulates the formal relationship between ADRCs and the MCOs.

2.    Illinois’ Governor’s Office should evaluate the utility and potential of integrating State Aging and Disability departments.  

3.    Providers and ADRC stakeholders should negotiate contracts with MCOs that go beyond the typical FFS model and allow for innovative new reimbursement methods.

Challenge: Adequate Legislative Oversight of MMC
Legislative governance is essential in order to ensure consumer protections and quality assurances in Illinois’ MMC system.

Opportunities for Adequate Legislative Oversight of MMC in Illinois:
Develop a Medicaid managed care legislative subcommittee under the auspices of the Human Services Committee.

Illinois has embarked on an ambitious plan to improve healthcare, improve population health, reduce healthcare costs, and integrate medical services with social services that address the social determinants of health.  Recognizing the fluidity of state government and the political process, if Illinois takes advantage of the opportunities described in this report, the State will better position itself to achieve these goals.  

While MMC is not the silver bullet that will single handedly achieve these goals, MMC—along with Illinois’ many other health care reform initiatives—has the potential to move use closer to realizing them.  Integrating LTSS into managed care is an important piece of this puzzle as this allows the state to address the social determinants of health.  Through leadership and collaboration across stakeholder groups, Illinois can position itself on a stable course of reform and has the potential to become a leader in MMC including serving LTSS customers.

Jul 15, 2013 Written By: Kristen Pavle

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
Mar 28, 2013 Written By: Janna Simon

Moving on, but not leaving behind: My reflections on my time at Health & Medicine

As I reflect on my time as the Senior Policy Analyst and Schweitzer Program Associate at Health & Medicine, I am inspired by the hundreds of friends and colleagues I have met who tirelessly fight for justice and equity. One cannot do this work for years without the support of like-minded people joining you in the journey.  I am thankful for the network of advocates I have become part of and for the chance to get to know so many organizations across this city and state.

For me, Health & Medicine will always be the place where I developed my skills in policy and advocacy, and fostered by passion for justice and equity.  From working with safety net providers, researchers, and systems leaders developing recommendations for the region’s health system, to participating in grassroots coalitions on charity care, Health & Medicine supported my growth, calmed my concerns, and inspired me to continue to fight for what’s right. As I move forward in my career, elements of Health & Medicine will always remain, and I will never forget the lens by which we view the world.  It is forever engrained in me.

Of course, I have to give special thanks to my coworkers and Board members, especially our Director, Margie Schaps, and Chairman, Dr. Quentin Young. Quentin is the soul of this organization and Margie the heart.  I am inspired daily by Quentin, continuing to serve in his retirement because he can’t imagine doing anything else. Hearing him speak about his time as a civil rights doctor and how he was fired twice at Cook County for standing up for what’s right, his legacy will follow me throughout my life.  I strive to achieve half of what he’s accomplished for world justice, and am glad I can call him my friend.  Margie has been a personal and professional mentor for me, teaching me how to navigate the politics of policy and remain on course for equity. She officiated at my wedding and provided countless hours of support. While I may be leaving Health & Medicine, I know I’m not saying goodbye to my friends.

It is with bittersweet sentiment that I leave Health & Medicine, following my passion for obesity prevention and promotion of physical activity and nutrition.  Health & Medicine has set the foundational framework through which I see the world, and will never be forgotten.  To all of my colleagues, thank you.  I look forward to continuing to work toward justice.
Feb 06, 2013 Written By: Health & Medicine Policy Research Group (HMPRG)

HMPRG Forum on Community Health Workers Featured in Crain's Chicago Business

HMPRG's Janna Simon was quoted in a Crain's Chicago Business article on the January 25th forum on community health workers. Janna and HMPRG board member Joe Zanoni are featured in the slide show of photographs from the event accompanying the article.
Feb 05, 2013 Written By: Health & Medicine Policy Research Group (HMPRG)

HMPRG’s Kristen Pavle contributes to ASA Journal article on The Bridge Model

HMPRG’s Kristen Pavle co-wrote an article with colleagues from the Illinois Transitional Care Consortium (ITCC) on the Bridge Model of transitional care for the American Society on Aging’s journal, Generations. To check out the article please click here

HMPRG has been involved with Bridge since 2008, playing a leadership role with ITCC’s Program Management Team.  HMPRG’s work has facilitated ongoing Bridge Model improvement and implementation at sites across Illinois and the country. For more information on ITCC and Bridge, visit the ITCC website at,or contact Bonnie Ewald, or 312.372.4292 x 31, Program Coordinator at HMPRG.

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