AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
ANN MARIE MURPHY: Thanks. I'm really delighted to be here in a venue other than Medicaid, because I do think that Medicaid interacts with a wide range of other programs and it is incumbent upon us all, in fact, as Kay has been talking about, to create those linkages.
I'm here to talk about the work that's going on in Illinois today. And Illinois definitely is a state that is, in some senses, beating of a different drummer. We hope that we can give hope to those of you that have been dancing in a different dance, because I know that most of you in this room probably would prefer to be dancing to the dance of expanding access for children and improving services.
We're lucky that the Governor in Illinois, Governor Blagojevich, is supremely committed to expanding access for children, improving the quality of care, and has been willing to put money where his mouth is by actually putting the money to doing these expansions.
You might also ask, why dwell on Illinois? There are lots of other, maybe more interesting states, depending on your point of view. However, one of the interesting points about Illinois is that it is the most demographically representative state in the nation. If you look at Illinois, we have some very strong urban areas. We have suburban, and we have a lot of rural. We have 66 percent of the population residing in Chicago and the surrounding areas. However, we have a lot of rural. We also have a lot of ethnic diversity, racial diversity. Pretty much everything resides in Illinois.
And so when you look at solutions, sometimes it can be a real challenge to find solutions that work all across the state because of diversity, the different cultures, the different types of populations, the different demographics can be quite a challenge.
I work in the agency Health Care and Family Services. We actually in the last year or two have changed our name to really more focus on our mission, Health Care and Family Services. We used to be called Public Aid, which I hated, as did our beneficiaries. Nobody really wants to go to the Public Aid Office, so we changed that.
We have been undergoing a lot of changes in the last few years. The first and foremost is to thinking of a Medicaid program not as a cost center. Traditionally in Illinois, over the last maybe 10, 12 years, Medicaid has been thought of as a large cost and a cost center, a cost that needs to be controlled, but not necessarily as a health care program.
Over the last few years, under Governor Blagojevich, we've actually changed that to really believe this is actually a health care program. We are currently going to change our entire delivery system for 1.2 million beneficiaries to move from what is currently a primarily fee for service system to be a primary care case management system, which will prioritize medical homes and the delivery of services based on a medical model.
Why look at Medicaid? As I mentioned, we already cover 1.2 million children. That's about a third of state's children. It's not as if providers divide their practice and change somehow how they treat children depending on who walks in the door, at least we would hope so. And so therefore, if you make changes in a Medicaid program, you can really drive change right across the whole delivery system. We certainly found that in the area of drugs, we have a preferred drug list. When we change our preferred drug list, sometimes to the chagrin of the pharmaceutical companies, prescribing patterns change too. And so sometimes those companies that were less willing to give us a good price become very enthusiastic. So we do know that in day‑to‑day that Medicaid policy does make a difference in practice.
We'd like to do more than just change prescribing and pharmaceutical delivery systems. Our aim is to actually improve the quality of care for all children in Illinois, and that's why we're focused on Medicaid. Our Medicaid program is linked with our (inaudible) program. We call it All Kid Care. It's all the one program, in essence. The same delivery package. We wanted to de-stigmatize Medicaid, and so that's why we changed everything to be kid care. We never mention public aid or Medicaid in any of our literature.
So we are covering 1.2 million children. However, there's still about a quarter of a million children that are uninsured in Illinois. And this lack of insurance, it drives up everyone's costs. It really is not good for anyone when children are uninsured. There's cost shifting from one payer to another. Private policies in Illinois, according to recent study by Families USA, a thousand dollars more expensive due to cost shifting from the uninsured generally.
We also know, and I'd be preaching to the choir here, we all know that health care and the access to health care, we spend $20,000,000,000 on education in the state. So given this, bearing this all in mind, the governor, therefore, last year, during veto session, pushed through a plan to cover all uninsured children. We call this the All Kids Program. It will be starting this July. And as of July, all children, irrespective of income or immigration status, who are uninsured, will have access to publicly‑funded health insurance through the State of Illinois.
The program is built on the Medicaid and the (inaudible) program. So therefore, it has the comprehensive EPSDT like a level of services. It's not free. It's actually affordable. There are sliding scale premiums and cost sharing. So therefore, those that are ‑‑ have more income, will pay more, will pay more in cost sharing. In fact, at the upper levels, the cost sharing will look very much like private insurance.
Some would say, why did you cover those that have income? Well, there are a certain number of children that are uninsurable because of their health care needs. And we didn't really want to get into the populism of saying, well, they're out because they're wealth. So therefore, in that income bracket, they actually buy in.
The other benefit of having it as all kids, is that it really is for all children. Just like Medicare is for all seniors. And therefore, has more political support often than Medicaid. Having a program that is for all children, I think, will de-stigmatize the State's program in general. Therefore, it will have benefits for all.
You know, having a card is just not enough. We could all have an insurance card, but we all know that what you really need from your insurance card is not something for your wallet. It's something that actually gets you access to services. And that's why, at the same time that we're instituting the All Kids Program, we're changing our model of deliver to be a primary care, case management program that insures that every family has access to a family provider.
We think that advantages of that over a regular fee for services is that we will then be able to coordinate care, providers will know all of the care that their beneficiaries are actually receiving. We will provide information, if a provider gets a new patient as to services that were rendered in the previous six months.
We hope that this will help us do more in the areas of EPSDT, especially in regards to immunizations and other important screenings. So that we know what children are getting, and that when they aren't getting what they need, that we can then do outreach.
We're also instituting incentives for physicians and community health centers to pay them a bonus pay in the upcoming years. Where, if a child is fully immunized, they can actually get a bonus. Often it's my belief that money often drives action, and we will be interested to see how this actually works.
We hope that we will be able to, therefore, interact with providers and provide them information back so that they know how they're doing. As I said, this program will really focus on preventative care. It hopes to eliminate unnecessary ER visits and other unnecessary and duplicative services. That way, it actually saves money and improves the quality of care. That's certainly the notion that other states have primary care case management programs. They vary a lot. I think the proof is often in the pudding. We will have to have a very strong evaluation component and see what really happens. But the good news is because each provider will be accountable for their patients, there are mechanisms so there can be interactions back and forth.
So my belief, and I think certainly the strong belief of our governor is that, states do have a lot of opportunities to enact positive change. We cover so many children in a wide variety of programs, that we have the opportunity to reach out to a large number of children. To actually reduce the number of children that are uninsured and to interact with all the different programs to link them together so that they work together rather than as fragmented silos.
We also have the opportunity to pilot new strategies, measure them for success. And then, if they are in fact successful, to systematize them. So we believe that the time is really now to make positive change. Critics will say, how can you afford this? I think our answer would really be, is how could you afford not do this? If you spent $20 billion on education. Spending what All Kids will cover in the first year is a mere $20 million. Twenty million to cover all children, when you're already spending $20 billion on education, it seems like a rather minor investment in our children's future.
Medicaid, it's interesting people sometimes say it without a wonderful, positive glow. However, one of the great things about Medicaid is that it is a program that can be very innovative. It has a very broad menu. EPSDT, you know, those of us that have been sued under it, you know, might think of it as a swear word. But in general, it is a service that can really cover what children need.
For instance, those items that are federally mandated, such as developmental screening, including mental health, anticipatory guidance, referrals, those are obviously all things under EPSDT.
Other things that Illinois has been doing recently is to move towards objective developmental screenings. We've unbundled the code and paid for them separately. Because again, often reimbursement drives behavior. We've also looked at new ways to provide services, which I'll get to in regards to those that are not covered under a plan, but whose child, if a woman is not covered anymore under our program but a child is, we've been looking at ways to actually provide service.
We've also been looking a lot at the area of perinatal depression. All of these efforts which we've been doing, in collaboration of a wide variety of individuals, have led us to understand some pretty key, and some would say, obvious point. First and foremost, provider involvement is key. Without providers involved, you really can't get anywhere, given that they are the individuals that are providing the service.
We've been involved in physician training with our Academy of Pediatrics, our family physicians and maternal and child health advocates and others. We have been involved in the Commonwealth, (inaudible) ACDT II Project. That has meant that we've really been able to focus on interacting with providers in all sorts of different settings.
We've worked on education with providers in regards to screening tools, reimbursement policy, claims submission, helping them to bill us. There aren't all that many insurers that actually go out and help people get money from you, but we do do it because we think it's actually important.
We've been working on anticipatory guidance and referral resources. The referral resources is key. A lot of physicians and other providers will not screen when they don't know what to do next. If they don't have anywhere to refer and they don't really know what they should be doing, then they're unlikely to do. So we think that the referral resources is very, very important.
We've been doing a lot of piloting of new strategies. And then our aim is to gather very succinct data, because we find that, in general, you can't systematize change until you can prove to your budget office that it was worthwhile. So that, I think, is a key lesson that we learn every year.
Partnerships. Obviously, they are key. As we've mentioned here, um, there are a lot of different systems in play in all different states. And one of the things is how do you actually effectuate the right kinds of linkages?
In Illinois, just like most states, we have an early intervention system. It's key that we interact with the early intervention and we insure that those that are screened through Medicaid then can get the appropriate referral to early intervention. That's something that we've been working hard at.
We have a family case management program for children, pregnant women and children at risk. We've been working with that family case management program and with WIC to insure that those linkages are in fact made and that they are doing screenings. That we're teaching, educating and really emphasizing the importance of some of these screenings for young children.
We've been working also in collaboration with others. We know that many providers, for instance, most of our beneficiaries go to family physicians, pediatricians, and others who may not have as much training in mental health as one might like, for instance. That it might not be their area of specialty.
And so we developed a collaboration with the University of Illinois at Chicago, where they have a consultation service that is available to all our providers. They can call, they can get advice on how to treat, how to screen, how to deal with all aspects. And that definitely is very actively used and much, I think, appreciated by our providers.
Of course, the key question here is, you know, how do you actually pay for this? That's always where the rubber hits the road. We have used Medicaid Match. It's interesting. You can get foundations to give a Medicaid agency money, provided it is not actually a provider. There's some definite provider donation rules.
If you put it in a trust, you can then, working with CMS, get it certified that it really is to local match, and you can then draw down federal match. We've done that on several instances to do new projects to test out models. We've generally said that, if we find them successful, we will systematize them. But it is a great way to actually fund some new projects when your state is not in budget‑flush times.
We've also worked with local entities. A lot of local entities, you'll find, we all find, do a lot of health care work. And they may not necessarily be claiming all the federal match that they can. So we've been working with our local health departments and other government entities to insure that any of the outreach and early childhood work that they're doing, they're maximizing their federal match. We help them claim for that.
We did recently a state plan amendment and for legal government entities to insure that they can recoup the maximum amount possible. We've also been looking ‑‑ you know, EPSDT is very flexible. So it does allow for a lot of claiming in that area. So that's something that I think those of you that are looking for those last few dimes, look at what you're claiming for now and see that there's probably more that you could claim for.
With respect to perinatal depression, you know, the reasons for why we are interested in that are pretty obvious. The prevalence rates are much higher for those with low socio‑economic populations. And maternal depression clearly affects child's developments.
This can be clearly covered through EPSDT. And we believe that you can cover this through comprehensive prenatal and postpartum care as a Medicaid‑covered service. We have now added reimbursement for that. We will allow, not only screening of a mother when she's covered through our program, which we cover a very large ‑‑ it's about 45, maybe sometimes 48 percent of Illinois births. So we can cover during the prenatal period and postpartum.
But even after that, if a woman loses eligibility, we are covering through the child. So if the child's visit, if there's a screening for peripartum depression for the woman, that can be covered through a risk factor for the child.
And in regards to, this is just sort of a dull codes that we cover, in regards to the record documentation, that documentation may either be kept in the child's chart, or some physicians will keep that as a separate chart for the mother. But that is something innovative that we've been doing to insure that children get the most from their coverage, including coverage for the mom for this rather important screening.
We also cover developmental screens. These are just the codes that we cover. Again, plenty, in regards to the sort of documentation, I'll get later to actual results. Most have you probably have states that cover a large number of children through managed care. Actually, in Illinois our participation in HMO‑based managed care is very low. However, we do have some.
And that has been quite a challenge in regards to data and insuring that we know what we're specifically buying from our managed‑care partners. So therefore, we've been engaged in some recent collaboratives to look at EPSDT and prenatal care to look at baseline data and to insure that we're actually, you know, really providing the type of quality care that we want. We've been measuring and remeasuring and then providing feedback to our HMO providers.
However, there are plenty of challenges, both with our HMOs and also with encounter rate clinics. Because in those settings, one is paid a bundled rate, sort of an encounter rate. So it can be quite difficult to get details, billing data back. So we're working with our community health centers to try to improve this so that we can, in fact, know what services children are getting. So that when we have outreach strategies, we know who we should be outreaching too. This is quite a challenge. However, our state culture groups are working a lot on this. We have the same issue, as I said, with HMOs. So therefore, we're looking at new ways to (inaudible) by the reimbursement rate or withhold, so we get what we believe we paid for.
The proof is really in the pudding, so to speak, with the early results, while the codes that are billed 44, for instance, perinatal depression, may cover other items. However, all our focus in the last year has been on improving awareness of the need to screen for perinatal depression. And so, you can see that the results in regards to women's screening have been rather large. It's nearly at the four‑fold increase, three‑ to four‑fold increase in women's screened.
Likewise, for children, the increase is not as high, but it certainly is significant. We hope that with the new primary care case management system, that we can do even more to identify who is being screened and who is not being screened, and that we can interact with providers to insure that these results get even better.
I think that the main message that I would have for all here is that Medicaid really can have a very positive impact. We do this in a way ‑‑ obviously, we do have an inspector general and they do their work. However, all the work in this is really very collaboratively done. It's working with providers, with state (inaudible), working out what will be the solutions that work for them in their own settings.
And it's important that we not impose things that we work with, individuals to work out solutions that really work in the real world, and not just in my office. We've been working, as I said, with our managed care companies, with the community health centers and we are embarking on this large change.
We've learned a lot from these particular travels. We believe very strongly that investing in child health and development early, positively impacts the future. That it's money really well spent. Our critics certainly say that, you know, how ‑‑ again, how can you afford it? But really, how can you not afford to do this? It's really pay now or pay a lot more later.
If you look at Medicaid costs, they're not growing really that much on the children's side. Where our costs are, are on seniors and persons with disabilities. Not that any of us would be suggesting that those aren't worthy items to pay for, but if we can in fact decrease the number of persons with disability in regards to insuring that people are healthy, and that they don't develop issues later, then we will ‑‑ that is a much, much more cost‑effective manner than just cutting Medicaid.
Really, nothing good comes when you cut Medicaid. Not only do you lose your federal match, but people lose their health insurance. When they lose their health insurance, they get their treatment in emergency rooms and in other acute settings. It costs the overall state far more. So we believe Medicaid has a very large role.
The Urban Institute did a study for us that showed that the publicly‑funded system was, in fact, 54 percent cheaper than buying the same services in the private sector. So we think that this is an efficient way to go.
That isn't to say that there aren't tough choices. You always have to think about what you're covering and what you're not covering. For everything that you cover, there are choices of things that you can't cover. So you do have to look at the data and sometimes make some choices that you would prefer to just cover everything.
Feedback is clearly vital. And we really believe that working together with partners, one can come up with a strategic, planned vision that expands access to children, to the services that they need, and that this is a good investment in all of our futures. Thanks.