Illinois Medicaid abuses part of system in crisis

Illinois Medicaid abuses part of system in crisis

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When Governor Pat Quinn announces Medicaid cuts from a Springfield podium next week, Dr. Jason Grinter will be inside a Chicago operating room, treating Medicaid patients. 

Grinter is a dentist whose appointment book includes hundreds of Medicaid clients, many of whom have no other access to dental care. Dental services are among the benefits lawmakers are considering cutting back on as they look for ways to reduce the cost of the state’s health care system for the poor, which has been described by players on all sides as a mess.

“When you go without dental care, you get infections. You go to the emergency room,” Grinter said. “That’s big bucks. The state will be spending twice as much if it gets rid of the dental program. It’s so short sighted.”

To Grinter, who treats children, the elderly and the disabled—often in school gymnasiums or nursing home cafeterias as part of a mobile dentistry outreach—the potential loss of Medicaid coverage for his patients reflects chronic failures within Illinois’ system. 

From the first stage of enrolling patients, through treatment and payment, Medicaid is bogged down by fraud, inefficiency, unsustainable costs and a paralyzing political climate of influential doctor, hospital and health care lobbies, according to lawmakers and health care organizations who work within the system.

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Even the most basic reform—verifying the addresses of Medicaid enrollees to make sure they live in Illinois—has taken more than a year to implement, due to federal bureaucracy, and is only now beginning.

“It’s a mess. An absolute mess,” said Dr. Wayne Polek, president of the Illinois State Medical Society and an anesthesiologist. “It’s only going to worsen in the next couple of years.”

The federal government’s Affordable Care Act will move more people toward Medicaid starting in 2014, a transfer Polek described as “disconcerting” in a state facing $9 billion in unpaid bills, about $2 billion of which are Medicaid-related.

To reduce spending, Quinn said he wants to move Medicaid patients into more stable care and cut the reimbursement rate, the amount of money the state pays doctors for treating Medicaid patients. He is expected to outline specific changes during his budget address on Wednesday.

Some lawmakers said the state also needs to tighten eligibility. But that’s a complicated task. The federal government has blocked states from kicking Medicaid recipients off the rolls. Most of Illinois’ Medicaid clients are pregnant women, children, the elderly and the disabled.

The program has nearly doubled from 1.4 million enrollees in 2000 to 2.7 million in 2011. According to a recent report from the Civic Federation, costs for Medicaid could reach $12 billion within the next five years.

“We want to cover the people Medicaid was created for. It was supposed to be a safety net for low-income people,” said state Rep. Patricia Bellock, Republican of Westmont, who serves on a Medicaid reform committee.

She said expansions of the program and the state’s failure to enforce eligibility rules have overwhelmed the system. The fragile population for whom Medicaid was created cannot find physicians willing to take them.

“It’s gone full circle,” Bellock said.

Currently, Medicaid applicants are required to produce one pay stub to show their income level. They do not have to provide official identification, such as a driver’s license. They are asked for a Social Security number, which the state’s Department of Healthcare and Family Services uses to try to verify addresses, according to Illinois Department of Healthcare and Human Services spokesman Mike Claffey.

Those requirements are being tightened starting next month, but critics said the loose sign-up procedures for years led to uncontrolled enrollment and less accountability.

“There are a lot of people on the program who don’t belong on the program,” said state Sen. Dale Righter, Republican of Mattoon. “Some estimates are up to 20 percent. Government has been so lax and confirming eligibility has been so bad that they just leave people on the rolls. It’s supposed to be a safety net where you land, and then you get out.”

To fix the problem, the department has been negotiating changes with the federal government. The state needed permission to tighten eligibility rules mandated in a January 2011 law passed by the General Assembly. The law required all Medicaid applicants to provide one month of pay stubs and identification to verify an address. After a year of trying to work under federal rules, the state announced this month it would start using Illinois Secretary of State records and other electronic databases, including child support collection sites and tax returns, to make sure Medicaid users live in Illinois and qualify for the program.

Under current rules, a family of four earning about $33,500 annually qualifies for free health care for their children. A family of four earning between $33,501 and $67,056 annually pays a small premium each month, usually no more than $80, for child coverage.

Some lawmakers said the program needs stricter income requirements covering fewer families, which could result in thousands of children losing their coverage.

“The reforms that are needed go way beyond managing better care and reducing the amount of money we pay to providers,” Righter said. “It has to do with reducing the size of enrollment in the program and people losing their benefits. The problem is that bad.”

The Illinois Hospital Association and Illinois State Medical Society oppose Quinn’s idea to cut the rates doctors get paid for treating Medicaid patients. The state already pays per-service rates that fail to cover the full cost of providing the service. In dental care, for example, private insurance might pay about $75 for filling a cavity. For a Medicaid patient, the dentist receives only about $30 from the state after waiting, sometimes, up to six months for reimbursement.

The result is a shrinking pool of doctors willing to treat Medicaid patients.

“Our hospitals are doing their best with dwindling reimbursements at multiple levels,” said Maryjane Wurth, president of the Illinois Hospital Association. “There is a tremendous amount of anxiety over what all of this means and how we can continue to fulfill our mission to care for patients and to be here for our communities in the future.”

Eliminating dental services from Medicaid coverage is one option lawmakers are considering. Jason Grinter, who serves on the Chicago Dental Society’s access to care committee, is ready to fight to keep it.

“There is a tremendous demand for dental services, and it’s largely going unmet,” he said.

To better serve his own patients, Grinter packs his equipment and supplies into his car and takes dentistry to schools and nursing homes throughout Chicago and as far away as Rockford. He said he learned that Medicaid patients face greater barriers. It can be difficult for them to take time off work. A $10 bus ride or hiring a baby-sitter might stop them from going. They miss appointments. It can be frustrating for physicians, which is why only a few hundred dentists statewide take Medicaid patients regularly, Grinter said.

“You can’t force somebody to take Medicaid,” Grinter said. “A lot of dentists don’t want to bother with the paperwork. They would rather just do the care for free.”