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1
HOUSE JOINT RESOLUTION

 
2    WHEREAS, The General Assembly passed legislation and the
3Governor signed into law major reforms of Illinois' Medical
4Assistance Programs, including Senate Bill 2840, The Save
5Medicaid Access and Resources Together (SMART) Act (Public Act
697-0689) and House Bill 5429 (Public Act 96-1501) and these new
7laws intend to "address the significant spending and liability
8deficit in the medical assistance program budget of the
9Department of Healthcare and Family Services by implementing
10changes, improvements, and efficiencies"; and
 
11    WHEREAS, The reforms require the Illinois Department of
12Healthcare and Family Services to enroll at least 50% of
13recipients eligible for comprehensive medical benefits in a
14care coordination program by January 1, 2015; and
 
15    WHEREAS, Care coordination programs may be
16provider-sponsored programs that contract directly with the
17State or traditional managed care programs; they must operate
18integrated delivery systems where recipients will receive
19their care from providers who are responsible for providing or
20arranging the majority of care, including primary care
21physician services, referrals from primary care physicians,
22diagnostic and treatment services, behavioral health services,
23in-patient and outpatient hospital services, dental services,

 

 

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1and rehabilitation and long-term care services; and
 
2    WHEREAS, The Department must designate or contract for
3integrated delivery systems that ensure enrollees have a choice
4of systems and of primary care providers within the systems;
5and
 
6    WHEREAS, Payment for coordinated care must be based on
7arrangements where the State pays for performance related to
8health care outcomes, the use of evidence-based practices, the
9use of primary care delivered through comprehensive medical
10homes, the use of electronic medical records, and the
11appropriate exchange of health information electronically made
12either on a capitated basis in which a fixed monthly premium
13per recipient is paid and full financial risk is assumed for
14the delivery of services, or through other risk-based payment
15arrangements; and
 
16    WHEREAS, Health care providers, including hospitals,
17physicians and nurses, federally qualified health centers
18(FQHCs), nursing homes, home health agencies, social service
19organizations, and pharmacies can assume responsibility for
20coordinating the care of Medicaid recipients under a direct
21arrangement with the State that requires the providers to
22assume increasing risk over a short period of time; and
 

 

 

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1    WHEREAS, In order to achieve significant savings needed to
2cover administrative expenses and generate profits for
3shareholders, HMOs often prevent beneficiaries from getting
4the services they need; Medicaid HMOs in Illinois have
5previously placed barriers to care, and in some instances,
6either reduced rates to providers or made it very difficult for
7providers to get approvals to provide the care that people
8need; major policy reviews of various studies on Medicaid HMO
9managed care have found little savings from HMOs and that such
10an approach is unlikely to significantly lower costs; and
 
11    WHEREAS, HMOs in Illinois have a checkered track record in
12"managing" Medicaid patients; Illinois failed in its first
13major attempt to enroll a large number of children into a
14managed care program, the Healthy Moms/Kids program, which was
15scrapped in 1995 after having failed to meet performance
16standards and spending millions in failed computer systems; the
17State also scrapped the ambitious MediPlan Plus program; and
 
18    WHEREAS, Even more concern should be given to the 2004
19federal court ruling in Memisovski v. Maram that HMOs provided
20less preventive and primary care and poorer quality care to
21children in the Medicaid program in Cook County than non-HMO,
22fee-for-service programs; and in 2008, an HMO in Illinois paid
23$225 million - the largest jury verdict in a false claims case
24in U.S. history - to settle charges that it deliberately

 

 

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1excluded pregnant women and sick people from its program; and
 
2    WHEREAS, The 50% goal must be achieved by enrolling medical
3assistance enrollees from each medical assistance enrollment
4category, including parents, children, seniors, and people
5with disabilities only to the extent that current State
6Medicaid payment laws would not limit federal matching funds
7for the State; and
 
8    WHEREAS, Moving most or all recipients to full-capitation
9HMOs will contravene federal rules, cause the State to exceed
10the federal upper payment limit and thus jeopardize up to $1
11billion in federal funding under the Hospital Assessment
12Program; and
 
13    WHEREAS, The Illinois Department of Healthcare and Family
14Services has selected only a limited number of
15provider-sponsored Care Coordination Entities while giving
16preference to health maintenance organizations; another
17solicitation of interest could ensure further expansion of care
18coordination beyond mandatory HMO enrollment; and
 
19    WHEREAS, The State should thoroughly evaluate its
20experience with HMOs before substantially increasing mandatory
21enrollment in these types of plans; hastily moving large
22portions of the Medicaid population into HMOs (i.e., 1.5

 

 

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1million to 2 million) is inherently risky; and
 
2    WHEREAS, Given that the Department is planning more
3aggressive use of HMOs, all policymakers should know that there
4is little evidence to date that the initiatives will contain
5program costs; Illinois needs to be far more cautious and
6conservative in estimates of the likely benefits of HMO
7Medicaid managed care; the State should work with providers to
8develop innovative partnerships that share risk, rather than
9abdicate responsibilities to HMOs, which often achieve savings
10by denying services or reducing payment; and
 
11    WHEREAS, Hastily moving large numbers of Medicaid
12recipients to full-capitation HMOs will jeopardize up to $1
13billion in federal funding under the Hospital Assessment
14Program; care coordination must be carefully designed so that
15the State does not jeopardize the funding provided by the
16Hospital Assessment Program; therefore, be it
 
17    RESOLVED, BY THE HOUSE OF REPRESENTATIVES OF THE
18NINETY-EIGHTH GENERAL ASSEMBLY OF THE STATE OF ILLINOIS, THE
19SENATE CONCURRING HEREIN, that we urge the Department of
20Healthcare and Family Services to carefully evaluate and
21reconsider its actions to quickly move larger numbers of
22Medicaid beneficiaries into HMOs; and urge that the agency
23refocus its current preferences and give more favorable

 

 

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1consideration to innovative, provider-based care coordination
2strategies; Accountable Care Entities should be utilized as
3important and valued alternatives to traditional HMOs; these
4models bring together a wide variety of entities such as
5hospitals, physician-led groups, Federally Qualified Health
6Centers, social service organizations, pharmacies, and
7behavioral health providers and closely resemble the
8Accountable Care Organizations (ACOs) that participate in the
9Medicare Shared Savings Program, under which these entities
10provide care coordination services to seniors and adults with
11disabilities who have the most complex physical health and
12behavioral health conditions by facilitating the delivery of
13appropriate health care and other services and managing needed
14transitions in care among providers and community agencies; and
15be it further
 
16    RESOLVED, That the General Assembly recommends that the
17Department of Healthcare and Family Services should more
18actively pursue provider-sponsored care coordination in the
19Medicaid program, including application for relevant federal
20grants and Medicaid waivers; and give provider-sponsored
21entities a more meaningful and substantive opportunity to
22succeed, because provider-sponsored care coordination, done at
23the local level, is best for patients.