Introducing CountyCare
This coordinated approach to Medicaid relies on federal funding and partnerships to deliver upfront care in the doctor’s office By Bruce Japsen
For years, Medicaid insurance in Illinois has been known for its low reimbursement and a bureaucracy that has slowed payments to physicians, dampening enthusiasm for the program and hurting access to care for patients. But help could be on the way, particularly in the Chicago area, where Cook County Health and Hospitals System administrators have engineered a new health insurance program designed to improve care coordination and increase quality for an expanded pool of Medicaid patients. And for physicians, the program by law, must speed payments to doctors and make relationships between the historically troubled state Medicaid program and doctors less cumbersome.
A Shot in the Arm for the Quality of Life
The new health insurance program is called CountyCare. It began as a demonstration project under a federal waiver, and this year was made permanent, through a cash infusion under the Affordable Care Act (ACA), bringing Medicaid health insurance to tens of thousands of once-uninsured adults in Cook County. “There are now 90,000 adults in the county who have the dignity and flexibility to show up at myriad providers and say they are insured,” said John Jay Shannon, MD, a pulmonologist and chief executive officer of Cook County Health and Hospitals System and a 25-year veteran of the medical staff of county-owned John H. Stroger, Jr., Hospital in an interview with Chicago Medicine. “That is a huge shot in the arm for their quality of life.”
But unlike the traditional Cook County health system, which treated those who couldn’t afford to pay and who often showed up as a last resort, typically when they were sick and in need of hospitalization, these newly insured patients who sign up for CountyCare can now get care upfront in a less costly doctor’s office or clinic setting. This covered care also includes traditional outpatient and hospitalization benefits, prescription drugs, mental health, lab services and myriad procedures and ongoing care from primary care physicians and specialists.
A key part of CountyCare involves a five-year $1.8 billion contract with health insurance company Centene Corp., which will run the third-party administration and support care coordination among CountyCare members. Centene, which also operates in other Illinois counties as IlliniCare, is one of the largest private administrators of Medicaid when it comes to state and other government contracts. Centene and its subsidiary health plans operate in nearly 20 states, often under a locally named brand.
The money, in the form of a per member per month payment of about $630 on behalf of patients who sign up for CountyCare, comes from the federal Centers for Medicare and Medicaid Services (CMS). Effective this year, the payment is funded entirely from funds under the ACA.
Since these patients had little or no money before to pay their bills, the infusion of money for health care services opens an entirely new business line for Cook County Health and Hospitals System. That money will also be used to pay doctors and expand the medical-care provider network to increase patient access throughout the county. “People without insurance did not have access to care,” said Steven Glass, the health system’s director of managed care, when referring to life before CountyCare and the ACA. “There was no one to coordinate it for them. Our hands were tied.”
Bringing an Army of Care Coordination Services
This means that previously uninsured patients will have more help navigating the health care system, with a call center and a 24-hour nurse line for questions. County officials hope that the navigation services will reduce the need for patients to come to the Stroger Hospital emergency room, where lines are notoriously long and care can be more expensive, which comes directly out of taxpayers’ pockets.
Along with the support of the insurance company, Centene, Dr. Shannon said Cook County doctors and other medical care providers will be “bringing a veritable army of care coordination services to the program.” “We will have web-based resources and information portals for members and providers within the network, so they’ll have that benefit,” Dr. Shannon said. “That should help us improve the experience of members. We’ll also have analytics on high-risk individuals, so we are adding that health risk assessment.”
Cook County officials are signing up those eligible when they show up at the emergency room or an affiliated federally qualified health center for CountyCare as well as the county jail, where inmates are often uninsured or tend not to have a regular primary care provider. To qualify for CountyCare, applicants must be adults aged 19 to 64 and live in Cook County. Incomes for applicants must fall below $15,282 for individuals or below $20,628 for a couple. For more information, providers and those interested can call 312-864-8200.
Once they are enrolled, patients will be given a health risk assessment as a way to assess what their chronic conditions are, which is often the first step in avoiding long-term illness and hospitalization down the road. “As an example, patients or members who have a mental health visit and are prescribed a medication that classifies them as being at higher risk, that information will seamlessly flow over to the medical case worker who can start to manage the totality of those members’ care,” Dr. Shannon says. “Previously, patients were not getting health risk assessments or getting well-coordinated care.”
Similar Markets Report a Drop in ER Visits
What the Cook County Health and Hospitals System administrators are attempting to do with the County’s uninsured patients has begun to reap rewards in similar markets that have previously implemented primary care medical home networks for Medicaid patients and the uninsured. In Milwaukee County, for example, a partnership of hospitals working with the Wisconsin Collaborative for Healthcare Quality uses health information technology and patient information to get patients who come to hospital emergency rooms to show up for follow-up appointments with primary care doctors and clinics. The Wisconsin effort, known as the “Emergency Department Care Coordination Initiative,” has so far seen a 44% reduction in the number of emergency department visits, according to Betty Ragalie, project director for the Milwaukee Health Care Partnership.
Studies show there are opportunities for financial benefits to Cook County as well as to the providers and patients. A 2004 study in the Annals of Family Medicine, for example, said health care costs in the United States would decrease by more than 5% each year, or more than $65 billion annually, if the U.S. health care system adopted medical homes. In addition, the study said that family physicians could use the efficiencies found in medical homes to increase their compensation or reduce their work time.
Great Expectations: A Growing Network and More Support
When patients show up at the Stroger Hospital emergency room, medical providers can feed information into the electronic health record-keeping system and hook them up to a network of primary care doctors and clinics. In Cook County, the health care system boasts of 138 “primary care access points” and a network of about three dozen hospitals and five academic medical centers, Glass said.
Cook County health officials also expect its network of doctors to grow. Glass said county health officials are also in regular discussions with independent practice associations (IPAs), clinics and other individual doctor practices that treat the uninsured. He encourages interested doctor practices to contact him. “We’re looking to expand,” Glass said.
Providers will also get more support than they are used to when working with Cook County. Teaming with Centene’s IlliniCare subsidiary and its provider relations systems, Dr. Shannon says medical care of patients should be better coordinated than it has been in the past, helping to improve relationships between Medicaid patients and the doctors and clinics who treat them.
CountyCare will work as a “sticky note” on a provider’s computer, as a reminder that the patient enrolled in the new health insurance program needs follow-up care such as a physical, Dr. Shannon said. It allows for better tracking than previously has existed when patients had no insurance and therefore didn’t seek care. Dr. Shannon and Glass both see the future as one where patients will end up achieving better health outcomes, and potentially save the county tax dollars.
A Long Road Ahead, But the Signs are Hopeful
In Milwaukee County, the effort to reduce emergency department visits through better care coordination and follow-up did just that. Over a six-month period in 2012, the partnership avoided an estimated $2.3 million in costs based on a 30% reduction in emergency department visits for uninsured and Medicaid patients who scheduled primary care appointments at their medical home, Ragalie said.
“Getting members access to care and linked to a primary care provider is our top priority,” Dr. Shannon said. “We know that once this is in place our members will get support to manage their care, their overall health will improve, and utilization and costs will stabilize.”
But Cook County health care executives know that it is not going to be an easy task to accomplish, nor will it change the course of how the poor and the uninsured are treated overnight. “I don’t expect it to turn on a dime,” Dr. Shannon said. “It’s going to take some time. We also need to be sensitive to low health literacy and let our members know that they can get support in between visits so they can begin to develop an ongoing health care relationship.”
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