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Foster kids in Illinois can wait months to see a child psychiatrist. Will switch to managed care cause ‘chaotic disruption’?

Chicago Tribune - 11/12/2019

Molly Hamilton wanted to find a new psychiatrist for her foster child, but the process wasn’t all that simple.

She needed a doctor who accepted Medicaid -- a requirement for youth in state care -- and specialized in treating adolescents. After many unsuccessful tries, Hamilton was placed on a waitlist. Eight months passed before an appointment with a new child psychiatrist opened up.

“We felt trapped,” said Hamilton, 37, who cares for three foster children in her Berwyn home. “Most places weren’t accepting new patients."

State officials say health care options will improve Feb. 1 when more than 36,000 current and former foster children are enrolled in a new Medicaid managed care plan. But foster parents, doctors and child welfare advocates are questioning whether the plan, which will be operated by a private contractor, has developed a network of providers equipped to handle the unique needs of this vulnerable population. Many children in state custody require specialized services after experiencing trauma, abuse or neglect.

Following a tense legislative hearing in September, the state Department of Healthcare and Family Services, which oversees Medicaid, announced it was delaying the rollout by three months.

“There is nothing more important to us than getting this transition right,” the agency said in a public letter. “This delay will help ensure a smooth transition and allow HFS and (the Illinois Department of Children and Family Services) to engage further with families, providers and other stakeholders and to monitor the managed care organizations more closely.”

On Thursday, the American Civil Liberties Union of Illinois asked DCFS to further delay the shift, saying that rushing the process will “result in chaotic disruption in children’s care, wasted time, and wasted money.”

The ACLU, which represents the state’s foster children in a long-running federal consent decree, named 14 areas of the plan that need further development. Specifically, the ACLU cited concerns about a lack of community-based behavioral health services that would allow children to be treated without being sent to residential facilities.

“We repeatedly have said that we do not object to the concept of managed care. Our goal instead is to prevent a rushed, disorderly and counterproductive rollout,” the letter said.

The private contractor, IlliniCare Health, has tried to assure critics that the transition is on track. When the plan launches, youth will have a six-month grace period to continue seeing out-of-network providers while new ones are located.

The ACLU, however, contends that six months is not long enough, and no child receiving specialized care should have to switch providers.

Before the ACLU filed its letter, HFS Director Theresa Eagleson said she didn’t expect to further stall the rollout.

"We feel like we are in a very good place, and we definitely believe this is an added value, an added service,” Eagleson said.

Eagleson said she was confident the new plan will provide better care to children than the current system. The plan, dubbed YouthCare, has contracted with more than 20,000 providers, accounting for 80% of Medicaid dollars spent on the youth in recent years, according to Eagleson and IlliniCare.

YouthCare has hired about 200 employees, including health coordinators and operations staff, who will conduct health screenings and help foster parents and former youth in care set up appointments and find doctors.

The plan will cover about 17,000 minors who are Medicaid eligible while in DCFS custody. YouthCare is also available to 19,000 former foster children, who were adopted or remained in a DCFS placement at age 18.

But some foster parents say they have many unanswered questions about the transition and are worried about having to forge relationships with new doctors. Physicians aren’t required to join the plan, and some major providers haven’t made a decision yet.

Northwestern Medicine, which operates large hospitals downtown and in the suburbs, is still exploring its options, according to hospital spokesman Christopher King.

“At this time, I don’t have a firm answer if or when our providers would be part of this network," King said.

Other prominent providers, such as Rush Health and Advocate Children’s Hospital, were in negotiations but had not signed a contract as of late October, according to both health systems.

Leyda Garcia-Greenawalt, a former foster child who leads a group of DCFS alumni, said she is concerned that former youth in care might be discouraged from seeking medical treatment if the process becomes more difficult or the transition is confusing.

Lawmakers have created a committee to hold public meetings about the change, but the meeting times are inconvenient for working people and haven’t been well advertised, Garcia-Greenawalt said.

“This is a population that needs the most health care,” she said. “You have a lot of unresolved trauma or perhaps abuse that never got looked at until now, and so you are almost disadvantaging these youth when you are switching things up on them and not letting them be part of the conversation.”

‘No one in our area to help’

The shift to managed care is part of a yearslong effort to reduce the state’s Medicaid costs while attempting to improve services for low-income and disabled residents who qualify for the federal program.

In 2011, lawmakers required at least half of state Medicaid recipients to enroll in a managed care plan by 2015. Former Gov. Bruce Rauner renewed that push in 2017 as he sought to have 80% of all Medicaid recipients, including DCFS youth, enter managed care. This summer, nearly 2.2 million Illinois residents -- about 76% of all Medicaid recipients -- had done so, according to the most recent HFS data.

With managed care, states essentially outsource the work of running the Medicaid program, said Anthony T. Lo Sasso, an economics professor at DePaul University. The logic is that for-profit companies will be more cost effective than the state at reimbursing providers and delivering high-quality care, Lo Sasso said. In return, the state typically pays the managed care company a fixed rate for each plan participant. That differs from the current model, in which the state reimburses providers for every service or treatment performed.

“The private plan has an incentive to make sure it enrolls efficient providers ... and looks out for waste and abuse and that type of thing in the system, and the state can get out of that difficult business," Lo Sasso said.

In fiscal year 2018, Illinois spent nearly $20 billion total in state and federal money on Medicaid, according to HFS.

An HFS spokesman said the department has not finalized the rates it will pay IlliniCare, which will vary based on the location or special needs of the children. He could not provide an estimate of how much HFS is paying IlliniCare to operate the plan.

Eagleson said the change is not motivated by cost cutting, adding that’s a common misconception.

“We believe that these children, as well as many others in the state, deserve coordinated whole-person health care,” Eagleson said. “Managing or integrating care is about that philosophy, not about saving money. It’s about providing better care to people.”

Foster mother Amanda Holbrook wants to know how the change will affect her family. Holbrook lives in Metropolis, a small city by the Kentucky border, with her husband and seven children -- three of whom they adopted, and four who are in foster care.

The Holbrooks are especially concerned about proximity to providers, a problem more acute in downstate and rural areas.

Holbrook said there are no dentists near her home that accept Medicaid and perform more complex procedures. As a result, she drives 60 miles to Carbondale several times a year to make sure all her children get checked out.

Under the new plan, Holbrook said she worries things will get worse.

“My biggest thing is are we going to start seeing more bills? Or are we going to have to start traveling farther and farther for appointments?" Holbrook, 35, said in a recent phone interview.

“We have two (children) who need counseling, and we have been on a waiting list for eight months for a counselor. There is no one in our area to help us.”

IlliniCare is still in the process of securing provider contracts for its youth plan. In some instances, YouthCare will contract with providers on a case-by-case basis so children can continue seeing a specific doctor, even if that doctor does not want to join the broader network.

IlliniCare, which also operates Medicaid plans for the general population, has participated in a number of town hall meetings and webinars for providers, trying to spread the word.

Will care improve?

Hamilton, who’s been a foster parent for four years, said DCFS has provided her little information about how YouthCare will work.

Hamilton said she first heard about the change on a Facebook group for adoptive and foster parents in Illinois.

The adoptive parents were posting about it because they received a letter in the mail detailing the change. But foster parents, who do not have legal custody of the children in their care, were not sent the same notification.

Eagleson said confidentiality issues delayed notification to foster families but that YouthCare is now beginning to contact them. From now until full implementation Feb. 1, health coordinators will screen children and assess their health care needs.

Hamilton, however, is not sure how the transition will play out. She said she likes the current system and has not had any problems after overcoming the initial hurdle of finding providers that accept Medicaid.

“Why are we changing something that is not wrong?” Hamilton said. “Can we spend our time changing the things that maybe do need to be fixed, that there are complaints about?”

Tracy Johnson of IlliniCare, who is leading the youth network, said the new plan was created to help foster parents like Hamilton.

As an example, Johnson explained, YouthCare can work out unique contractual agreements with providers in high demand, such as child psychiatrists, so children can get appointments during evening or weekend hours that wouldn’t normally be available.

“Our strategy is to bring in every provider that is currently seeing these youth, as well as add to that capacity,” Johnson said.

“The benefit of the care coordination team is we are able to navigate those systems and reduce those barriers that foster parents are currently seeing in the fee-for-service world.”

echerney@chicagotribune.com

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