Wes Venteicher, Chicago Tribune, Author at ��ýҕ�l Health News

Illinois Gov.’s Proposed Cuts To Mental Health Care Could Raise Costs, Critics Say

Wes Venteicher, Chicago Tribune — Mon, 13 Apr 2015 19:50:10 +0000

In the years before he started receiving consistent treatment for bipolar disorder, Illinois patient Rome Tucker says he often was homeless, riding buses through the night.

When he felt overwhelmed, Tucker often checked into Chicago-area hospitals for days at a time. The hospitals provided structure, support and medicine but at a high price: Tucker’s 16 hospital visits in 2012 cost about $50,000, according to IlliniCare Health, the Medicaid managed care organization that insures him.

Rome Tucker, 36, prays with his roommate Jarrod Landers, 20, left, at their apartment above Thresholds Psychiatric Rehabilitation Center in Blue Island on April 1, 2015. (Photo by Michael Tercha/Chicago Tribune)

Tucker, 36, now lives in a Blue Island apartment, sees a psychiatrist and takes medication regularly, and is working toward getting a GED. He visited an emergency room only once in 2014, and his care for the year cost about $6,000, according to IlliniCare. For these improvements the insurer credits Tucker’s transition to Thresholds, one of many providers of community-based mental health care in the state that Gov. Bruce Rauner has targeted for budget cuts next year.

Rauner’s proposal would reduce or eliminate funds for psychiatry, housing programs for the homeless and care coordinators who direct people with mental illness to appropriate care. Providers of the services call the proposal misguided, saying it would drive people like Tucker to hospitals, nursing homes, prisons and jails, where treatment costs are higher.

“It is short-sighted, because you’re just going to move people from one system that’s relatively cost-effective and inexpensive into a more expensive system,” said Eileen Durkin, president and CEO of Community Counseling Centers of Chicago. About 135,000 Illinoisans received community-based mental health care services in fiscal year 2014, according to the Department of Human Services.

Rauner’s proposal would cut about $82 million from the department’s Division of Mental Health, a 15 percent reduction, as part of an effort to close a budget gap he estimates at $6 billion for fiscal year 2016. All the governor’s suggested reductions face a long process of give-and-take before the General Assembly puts any of them into effect.

The governor’s office argues that the federal Affordable Care Act has reduced the need for state funding for mental health care services by expanding Medicaid and requiring private plans to cover mental health care.

People who qualified for state mental health care services but not for Medicaid can now sign up and get more of their care paid for by the federal government, requiring less funding from the state, said Department of Healthcare and Family Services spokesman John Hoffman.

But Medicaid doesn’t cover some of the services community-based providers say help stabilize people with mental illness, such as funding that helps people get jobs after mental health treatment. They also object to Rauner’s proposal to cut $13 million in funds that support housing for homeless people.

For other services, Medicaid pays too little, providers said. Among the items proposed for elimination is a $27 million “psychiatric leadership capacity grant” that helps pay for specialists like the one who now sees Tucker once a month. Medicaid pays such low rates for psychiatry that many organizations need the grant money to keep psychiatrists on staff, said Josh Evans, vice president of government relations for the Illinois Association of Rehabilitation Facilities.

With fewer psychiatrists, fewer patients will be able to get psychiatric care, whether or not they are on Medicaid, he said.

“We would be taking so many steps backward with the cuts that are on the table,” said Heather O’Donnell, Thresholds’ vice president of public policy and advocacy. “We weren’t a strong sector before and we would be a shell of that.”

Illinois cut spending on mental health by $187 million from 2009 to 2012, the fourth-largest reduction by percentage among states during those years, according to the National Alliance on Mental Illness.

Psychiatric and substance-abuse hospitalization increased by about 19 percent over those years, according to a Thresholds analysis of data from the Illinois Hospital Association.

The analysis posits that the data show a “strong correlation” between cuts to community-based services and increased hospital usage, suggesting the state paid about $18 million more in hospitalizations than it would have paid by keeping community-based services.

The state does not directly reimburse managed care organizations for each medical service Medicaid patients receive, IlliniCare spokeswoman Lindsey Artola noted. Instead, the organizations receive per-patient payments based on a variety of factors. The rates are adjusted each year based on total costs, and more expensive patients will eventually drive up costs to the state overall.

The state is paying IlliniCare $966 per month for Tucker’s care this year, up from $890 per month in 2013. But costs can shoot up immediately if a patient with mental illness begins receiving care in a nursing home or similar institution. Artola said the state would pay $5,934 per month if Tucker were admitted to a nursing home.

Another outcome for patients is jail or prison. About a third of people who enter Cook County Jail each day are mentally ill, and the county pays about $143 per day for each inmate, said Cook County Sheriff Tom Dart.

“It doesn’t make sense to cut service that prevents people from coming into the criminal justice system, which is a very expensive system to come into,” Dart said.

About 11,400 of the 48,000 inmates at the Illinois Department of Corrections receive ongoing psychological or psychiatric services, according to a department spokeswoman. Illinois spends about $38,000 per year on each inmate, according to an analysis by the New York-based Vera Institute of Justice.

As the state has reduced funding for mental health clinics in recent years, community-based services have expanded. About 140 organizations now provide community-based mental health care in the state, Evans said.

Hoffman, of the Department of Healthcare and Family Services, said the state’s new managed care system encourages insurers to coordinate patients’ care and find ways to provide some of the mental health services the state is reducing.

“This budget takes into account the new health care delivery environment, which builds care coordination, traditional services, medications and other crucial services into Medicaid primarily through managed care models,” he said.

Thresholds took on 50 of IlliniCare’s most complex mental health patients, including Tucker, in a 2013 pilot program. Over a year, hospital admissions among the patients fell by 50 percent and psychiatric inpatient care costs declined by 63 percent, Artola said. IlliniCare has since expanded the program.

Tucker said that in the past he sometimes chose to be homeless, rejecting offers to stay with his sister and her three children.

“I had no explanation for it,” he said. “I was running and I don’t know what I was running from.”

His criminal record shows arrests related to cocaine, marijuana, narcotics and alcohol. People with mental illnesses and limited support sometimes self-medicate with street drugs, said Jasmine Watkins, program director for Thresholds’ Medicaid managed care organization initiatives.

The organization determined Tucker was visiting hospitals because of “medication noncompliance” and started delivering his medicine to him, Watkins said, along with providing psychiatric services and group counseling sessions.

The hospital visits didn’t immediately stop when he started receiving services, but Thresholds staff encouraged Tucker to work toward his goals, one of which was to get away from the West Side. He moved in October 2013 to the Blue Island apartment, where he started receiving more intensive services and participating in group activities with other Thresholds clients at a nearby center.

He still struggles with drinking, he said, but takes his medicine regularly and believes he has left the rest of his West Side life behind him.

“This is a nice way,” he said of his treatment. “It keeps me out of trouble. It keeps me really focused.”

��ýҕ�l Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

This article/news/illinois-gov-s-proposed-cuts-to-mental-health-care-could-raise-costs-critics-say/">article; first appeared on KFF" rel="nofollow">">KFF Health News and is republished here under a

/?republication-pixel=true&post=533715&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

It’s Obamacare’s First Tax Season. Can The IRS Handle It?

Wes Venteicher, Chicago Tribune — Tue, 24 Mar 2015 09:00:47 +0000

Toward the bottom of the tax form most Americans fill out each year, just beneath a line for payments for maids, nannies and other household staff, there is a new line marked “health care: individual responsibility.”

Line 61 on Form 1040 comes from the Affordable Care Act, which last year started requiring most Americans to have health insurance or pay a penalty. But the law routed the penalty — and subsidies that help pay for insurance — through the tax system, assigning major new responsibilities to the Internal Revenue Service, an agency struggling with a shrunken budget, diminished staff and plummeting levels of customer service.

At a time when people still may be asking what health insurance has to do with their taxes, those seeking help from the IRS this tax season face historically long telephone holds, slow written responses and limited in-person help, according to the Taxpayer Advocate Service, an organization representing taxpayers inside the IRS.

The IRS has warned that the combination of new work and fewer employees could delay refunds. A miscalculation on health-related forms sent to 820,000 people is already delaying refunds for many. The IRS didn’t make the mistake, but the incorrect forms contain information people are supposed to report on their taxes, creating confusion. Some tax experts worry that more mistakes could be on the way as the agency processes millions of new forms.

“Overall, I do not believe they’re as prepared as they could have been,” said Kristy Maitre, an Iowa tax specialist who ended a 28-year career at the IRS last year, when she was a liaison to tax preparers for the agency. “I think there will be issues, but we aren’t going to know what those are until we get to the end of the filing season.”

Most of the country’s 150 million taxpayers just need to check a box on their tax form indicating they had coverage last year. No one needs to send proof of insurance. Insurers and employers were supposed to submit proof this year that the peoplethey covered were insured, but that requirement was delayed until next year, according to the IRS website.

But there are additional filing requirements for about a quarter of taxpayers, according to the Treasury Department. Those who didn’t have insurance last year must claim an exemption or pay a penalty. Those who received subsidies, which come as tax credits that reduce monthly premiums, need to show they received the right amount each month.

The Supreme Court is weighing a legal challenge that could strike down the subsidies in Illinois and about three dozen other states, with a decision expected in June. For now, the subsidies — and their tax requirements — remain in place.

How many people know any of that remains a question.

“I think there’s quite a bit lacking in people’s awareness of the law, the implications of the law and the opportunities of the law,” said Mark Steber, chief tax officer at Jackson Hewitt, a company that processes about 2 million tax returns each year.

Yet as of Feb. 21, just 40 percent of taxpayers who called the IRS reached a representative, and those who got through waited an average 26 minutes on hold — the worst level of service since the agency adopted its current performance measures in 2001, National Taxpayer Advocate Nina Olson said in written testimony to a Senate subcommittee.

Shrinking resources for the IRS

The wait time should be less than five minutes, IRS Commissioner John Koskinen testified to the subcommittee. Koskinen said the health law and other new requirements have added significant new work for the agency.

IRS's workload expected to grow

“I remain deeply concerned that the significant reductions in the IRS budget will degrade the agency’s ability to continue to deliver on its mission during filing season and beyond,” Koskinen said in written Senate testimony.

The IRS, which declined to answer questions for this story, had about 1,200 employees dedicated to the health law at the start of the tax season, said James McTigue Jr., the Government Accountability Office’s director of tax issues. The agency had stated it would need 2,046 workers dedicated to the law for the 2015 fiscal year, but Congress didn’t allot money for the hires.

Some members of Congress have said the IRS should spend its money more efficiently. Rep. Ander Crenshaw, a Florida Republican who heads an appropriations subcommittee, told Koskinen in a Wednesday hearing that the agency had overspent on executive travel, conferences and employee bonuses as well as mismanaging funds in other ways.

“We deliberately lowered the IRS funding to a level that will make the IRS think twice about what you are doing and why you are doing it,” Crenshaw said.

Congress has reduced the agency’s budget by 10 percent since 2010 and the agency has reduced its staff from about 95,000 people to about 83,000, according to the Taxpayer Advocate Service.

In addition to staffing concerns, some experts worry that technical systems being used for the first time this year carry the potential for delays and mistakes administering the health law’s subsidies and penalties.

Three to 5 percent of the nation’s taxpayers received the tax credits for insurance last year, according to the Treasury Department. The credits were based on income estimates for the year, and people who earned more or less than expected now either owe the government money or are supposed to get money back.

Insurance marketplaces send planholders 1095-A forms that they use to report any tax credits. The IRS verifies the reported information against Department of Health and Human Services data using an automated system.

The system is similar to others the IRS uses to match tax returns with external records, such as W-2s, but the IRS doesn’t normally start matching those records until July, after tax season is over, McTigue said. The agency is checking returns against marketplace data during the filing season, increasing the potential of delayed refunds, he said.

Maitre, the Iowa tax specialist, worries the agency could make mistakes matching the forms.

“There’s a potential of a lot of errors with that,” she said, noting that discrepancies often result in automatic violation notices to which taxpayers must respond or face penalties.

The IRS is also administering the penalties for people who didn’t have insurance last year, as well as processing forms for those who were exempt from the coverage requirement because of low income or other conditions.

This tax season, the penalty is $95 per adult and $47.50 per child or 1 percent of household income, whichever is greater, according to the IRS.

The agency has the authority to withhold refunds to pay the penalties but cannot issue tax liens or garnish wages as in other cases where taxpayers owe money, according to Lindsey Buchholz, principal tax research analyst at The Tax Institute at H&R Block.

Some tax experts wonder whether the health law’s requirements could have been simpler.

Michael Singer, a Northbrook certified public accountant, said some clients pay little attention to health-related forms that arrive in the mail. Many are unaware of the law’s specifics, which include an exemption from the penalty for people who went without insurance for three months or less, he said.

“Unfortunately a lot of people just don’t understand some of this stuff and they don’t realize how important it is to pay attention to some of it,” he said.

The law requires that health insurance plans meet a “minimum essential coverage” requirement, but determining which private plans meet the requirement is difficult, Singer and other CPAs said, especially since neither employers nor insurers are required to prove this year that their plans met the requirement.

Complicating matters for people with marketplace plans is that tax preparers often cannot tell whether a particular 1095-A form is one of the 820,000 containing a mistake.

The penalty for not having insurance will increase for 2015 to $325 or 2 percent of household income. Open enrollment for 2015 plans ended in February, but the federal government added a special enrollment period for people who didn’t learn about the penalty until filing taxes this year. Those people still need to pay the penalty for 2014 but can sign up for insurance through April 30 on healthcare.gov.

Singer said he monitors a stream of emails from the IRS for guidance on specifics. Having been through rollouts of new taxes before in his 44 years as a CPA, Singer said he expects the IRS to relax requirements if it makes mistakes that burden taxpayers.
“While we don’t know what they’re going to do, because it’s too new, I suspect that if they start seeing a problem, where something’s causing a problem for the taxpaying public, the chances are … they won’t penalize them,” he said.

The new requirements are even more complicated for small business owners and those who are self-employed, said Geoff Harlow, a tax partner at Deerfield-based accounting firm Kessler Orlean Silver.

“I’m not sure that I could come up with a better way to do it, but it’s difficult to understand, there’s no question about it,” Harlow said.

This article/insurance/its-obamacares-first-tax-season-can-the-irs-handle-it/">article; first appeared on KFF" rel="nofollow">">KFF Health News and is republished here under a

/?republication-pixel=true&post=529246&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

High Costs Of HIV Drugs On Some Illinois Insurance Plans May Be Discriminatory, Say Advocates

Wes Venteicher, Chicago Tribune — Fri, 27 Feb 2015 17:25:49 +0000

Two major insurers are charging much more than others for several common and AIDS medications in Illinois, drawing complaints from AIDS advocates that the companies may be trying to discourage high-cost patients from choosing their plans on the federal health insurance marketplace.

Several standard treatments cost more than $1,000 per month on many Coventry Health Care and Humana plans, while some of the same drugs cost as little as $35 on plans other insurers sell on the exchange, according to an AIDS Foundation of Chicago analysis.

“While certainly there are plans on the marketplace that offer good coverage, what we think these companies are doing is putting out a signal that people with HIV are not welcome on these plans,” said John Peller, the foundation’s president and CEO.

The AIDS Foundation warned Coventry, Humana and two other insurers in January letters that the way they are pricing the drugs may violate federal protections against discrimination. The forbids insurers from discriminating against people with pre-existing conditions.

Coventry and Humana lowered the costs of some of the drugs in Florida after nonprofits filed a federal complaint there, but prices remain the same in Illinois. Insurers noted that Florida has a state statute that specifically regulates coverage for HIV and AIDS patients, while Illinois does not.

The Illinois insurers said drugs’ rising costs, a changing patient pool and shifting costs of medical services all affect the way they price drugs and design plans.

“Our goals are to help our members be healthy and access the care they need by assisting with the strict patient compliance that these specialty medications require while keeping our health plans affordable,” Coventry spokesman Rohan Hutchings said in an email. All plans on the marketplace include out-of-pocket maximums that limit patients’ annual spending, he added.

Placing drugs for AIDS and HIV, diabetes, cancer and other chronic conditions into higher-cost categories, or tiers, within an insurance plan is sometimes called “adverse tiering” and has been documented by researchers. Patient advocates say the tiering may be a new way for insurers to keep high-cost patients off their plans, a common practice before the Affordable Care Act prohibited it.

A recent Harvard study published in the New England Journal of Medicine found evidence that insurers were adversely tiering HIV and AIDS drugs on 12 of 48 plans sold on the federal exchange in 12 states. People with midrange “silver” plans that were adversely tiered would pay about $3,000 more per year for their drugs than those in other plans, according to the study.

“We can’t say that the intent of these formularies is to discriminate, because we can’t read the minds of the people who made it,” said Dr. Benjamin Sommers, an assistant professor of health policy and economics at the Harvard T.H. Chan School of Public Health and one of the study’s authors. “But the result of these formularies is to discriminate.”

When Washington, D.C.-based Avalere Health looked at drug costs on silver plans in eight states, the consultant found more than a quarter of plans placed five classes of drugs — for HIV and AIDS, cancer and multiple sclerosis — in high-priced specialty tiers.

The AIDS Foundation of Chicago looked at how insurers tiered seven standard treatment regimens recommended by the Department of Health and Human Services. The foundation found that Coventry and Humana place nearly all of the drugs in the treatments in the fifth tier, their highest. Other insurers place some of the same drugs in lower tiers, resulting in lower treatment costs.

Because insurers don’t make public the discounts they negotiate with pharmaceutical companies, the foundation estimated costs based on average wholesale prices, which it says range from about $2,400 per month to about $3,300 for the seven treatments. Patients are required to pay half the cost of tier-five drugs on most Coventry and Humana plans, according to the analysis.

Nancy Daas, a partner at Chicago-based health industry consultant CMC Advisory Group, said the pricing of HIV and AIDS treatments is not the result of discrimination but a reflection of the costs insurers pay for the drugs.

“I’m not saying it’s easy for people (to afford them), but these drugs cost a lot of money,” Daas said.

A year’s worth of a common, single-pill regimen called Atripla costs $26,000 to buy wholesale, up from $14,000 a year when the pill was introduced in 2006, Humana spokeswoman Cathryn Donaldson said in an email.

“Humana is committed to working with pharmaceutical manufacturers and organizations representing individuals with HIV/AIDS and similar organizations for people with complex chronic conditions to develop longer-term strategies addressing these underlying concerns of pharmaceutical access and affordability,” Donaldson said.

Daas also noted that drug pricing affects the costs of other plan benefits, and vice versa. By charging more for certain drugs, insurers can lower monthly premiums for all planholders, she said.

The AIDS Foundation also sent letters to Health Alliance, which operates downstate, and to .

Health Alliance places all single-pill regimens, along with a drug commonly combined with others to treat patients, on the fifth tier in a six-tier system, resulting in “mostly unaffordable” drug coverage for people with HIV, the foundation wrote.

Health Alliance spokeswoman Laura Mabry noted that the insurer places several of its HIV drugs in low-cost tiers. “Our goal continues to be providing choices that meet consumers’ needs, including their prescription drug needs,” she said in an emailed statement.

UnitedHealthcare classifies most of the drugs used in the HIV treatments as tier two but also marks them as specialty drugs. Daliah Mehdi, the AIDS Foundation’s chief clinical officer, said the insurer told her the specialty designation made those drugs more expensive than others in tier two. But a UnitedHealthcare spokesman told the Tribune the drugs were not more costly.

In Florida, the AIDS Institute and the National Health Law Program filed a complaint over the cost of four treatments with the Department of Health and Human Services’ civil rights office. The complaint is still under investigation, but Coventry, Humana and two other insurers voluntarily reduced prices after a Florida regulator questioned whether the insurers were violating state law.

Coventry capped the costs of the four treatments at $200 per month, while Humana limited patient payments to 10 percent of what the insurer pays for all HIV and AIDS drugs on its specialty tier.

On Friday, the federal Centers for Medicare & Services issued a rule for 2016 that prohibits plan designs that place “most or all drugs that treat a specific condition on the highest cost tiers” and that charge more for single-tablet regimens than for treatments that require patients to take multiple pills.

About 37,000 Illinoisans had been diagnosed with HIV or AIDS as of December, with an average of 1,788 diagnosed each year from 2009 to 2013, according to the most recent Illinois Department of Public Health figures.

Information on how many HIV patients in Illinois have joined Affordable Care Act plans is not publicly available, but about 8,000 people who have received state help paying for their HIV or AIDS medication have signed up for a plan, joined Medicaid or are in the process of getting insurance, a health department spokeswoman said. About 9,300 people received help through the AIDS Drug Assistance Program last year, she said.

The state program now helps pay premiums and drug costs for the low-income recipients who have obtained insurance, along with those who are still uninsured, the spokeswoman said.

Patient advocates said lower drug prices would not only ensure access to treatment for HIV and AIDS patients but also help reduce the virus’ spread, as some of the treatments make transmission less likely.

Will Wilson, a 61-year-old Gurnee man who said he was diagnosed with AIDS 13 years ago, recently obtained insurance through his employer that covers nearly all the cost of his Atripla prescription.

After his diagnosis, Wilson said, he went broke paying for the 16 pills a day he took to keep the syndrome in check. Keeping his income low enough to qualify for state aid ultimately allowed him to afford treatment, he said. Now he works as an insurance navigator for a nonprofit organization, helping people understand their options.

Wilson said he thought the Affordable Care Act would bring a new measure of freedom for people with HIV and AIDS, but paying for treatment is still difficult for many. Even on health plans that pay relatively good rates for HIV and AIDS treatments, interpreting drug formularies and plan benefits to figure out a patient’s costs is extraordinarily complicated, he said.

“The system that was supposed to be easier for us is not easier,” Wilson said. “And once again we’re faced with (the question): We still have to fight for the drugs that keep us alive?”

This article/insurance/high-costs-of-hiv-drugs-on-some-illinois-insurance-plans-may-be-discriminatory-say-advocates/">article; first appeared on KFF" rel="nofollow">">KFF Health News and is republished here under a

/?republication-pixel=true&post=524487&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Critics: Medicaid Services Ill. Gov. Rauner Would Cut Save Illinois Money

Wes Venteicher, Chicago Tribune — Tue, 24 Feb 2015 10:00:48 +0000

Gov. Bruce Rauner’s proposed $1.47 billion in Medicaid cuts includes reductions in dental services, mental health care and other coverage. But some legislators and patient advocates say the targeted services don’t just help keep people healthy — they also save the state money.

Gov. Bruce Rauner delivers an address on his budget proposal at the Capitol in Springfield on Feb. 18, 2015. (Photo by Abel Uribe, Chicago Tribune)

The proposed cuts would eliminate or reduce coverage of adult dental care, podiatry, renal dialysis and hemophilia and funding of some mental health rehabilitation facilities, according to a budget document and a Rauner budget official. The cuts would also reduce funding for hospitals by about $735 million, according to the Illinois Hospital Association.

Many of the targeted patient services were recently restored to the Medicaid program after being eliminated a few years ago to save money, Rauner noted in his budget address Wednesday. Legislators who support the services say eliminating them cost the state more in the long run.

Regarding Rauner’s proposed cuts, Democratic Senate President John Cullerton said: “We already did that.

“We found, for example, that if you cut people’s dental services and then they don’t go to a dentist, they end up going to an emergency room and it costs us more money,” Cullerton said. “So we went back and examined that and made a change.”

“People will not miraculously get better if they’re denied care for services,” said Rep. Greg Harris, D-Chicago. “They’ll just end up at a higher level of care in an acute care setting at the most expensive end of their disease.”

Other legislators responded that the added costs of emergency room services have not been well-documented.

“It’s theory,” said Sen. Dale Righter, R-Mattoon. “The simple fact is that we can’t afford to pay for those services. We couldn’t pay for them at the time we repealed the services, we couldn’t afford them when they were added back, we can’t afford them now.”

The earlier service cuts were part of a 2012 Medicaid reform law called the Smart Act; it was later amended to roll back some of those changes.

The law instituted a process to determine how many people were on Medicaid who were not eligible to be. Rauner proposes saving $75 million by being more aggressive in determining eligibility and by adding new efforts to “detect and prevent fraudulent and abusive billing practices by providers,” according to the budget document.

Barbara Otto, head of Chicago-based Health & Disability Advocates, said people often seek help from her organization after being wrongly classified as ineligible.

“This is an old trick by a new governor,” to boot patients off Medicaid rolls, Otto said.
Medicaid’s budget for fiscal year 2015 is about $19.9 billion. Rauner’s proposal would cut spending to $18.6 billion for fiscal year 2016, a difference of $1.3 billion. The governor arrived at $1.47 billion in savings by including projected spending growth in programs he wants to eliminate, a spokesman said.

The proposed $735 million cut to hospital reimbursements comes at a time when 40 percent of Illinois hospitals are operating in the red, said A.J. Wilhelmi, the Illinois Hospital Association’s chief governmental relations officer.

“We think that that will set us back in transforming the health care delivery system and providing care to people in communities across the state,” Wilhelmi said.

Rauner’s changes begin with $200 million that hospitals pay in taxes. After a federal match, the hospitals currently get double that amount back, Wilhelmi said. Rauner would put the $200 million directly toward Medicaid costs and hospitals would lose out on the $400 million, according to the hospital association.

The remaining $335 million in cuts represents money the state reserved in reimbursements as it revamped a 20-year-old reimbursement system, the hospital association said. Hospitals were supposed to get the money back after the new system was in place, they said.

Patient advocates have also raised concerns about medications. The Smart Act restricted Medicaid patients to four prescriptions per month, with exemptions for HIV, cancer and organ transplant patients, said Samantha Olds Frey, director of the Illinois Association of Medicaid Health Plans.

In recent years, the state added mental health drugs and anti-seizure drugs to the exceptions. If the state returns to the Smart Act’s original prescription language, it would be a “life-threatening” prospect for people with epilepsy, Olds Frey said.

Rep. Patti Bellock, R-Hinsdale, who sponsored the Smart Act, said she has supported some changes to the law but not others. She said she expects to delve more deeply into potential savings and costs as the legislature begins the budget process.

“He has put these things out there; I think they need legislative feedback on what can be done and what can’t be done,” she said.

Tribune reporter Kim Geiger contributed.

This article/medicaid/critics-medicaid-services-ill-gov-rauner-would-cut-save-illinois-money/">article; first appeared on KFF" rel="nofollow">">KFF Health News and is republished here under a

/?republication-pixel=true&post=523471&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Disruptions Mount As Illinois Shifts Medicaid Patients To Managed Care

Wes Venteicher, Chicago Tribune — Tue, 10 Feb 2015 15:39:15 +0000

When Angelica Hernandez received a letter from the state telling her to pick a Medicaid managed-care plan for her daughter, the Naperville, Illinois, woman chose one that included the doctor’s office where she had always taken the 10-year-old girl.

After selecting the plan, Hernandez learned it didn’t cover the audiologist who had fitted her daughter, who is partially deaf, with a hearing aid. A Spanish speaker, Hernandez said through a translator that she was told it would cost at least $400 to see the audiologist under her new plan, and she has not gone back.

Officials at the Illinois Department of Healthcare and Family Services say they have tried to avoid disruptions of care as the state shifts 2.2 million of its 3.1 million Medicaid patients to managed care, a system in which the state pays a fixed amount for each patient instead of reimbursing providers for each test and treatment.

But some patients are reporting difficulties keeping their doctors and confusion navigating plans as they try to make the shift.

The reports include wrong information on websites for insurance plans and hospitals; hours on the phone with insurers, hospitals and a state contractor who helps with enrollment; conflicting letters in the mail; changes to prescriptions, and other frustrations. For Hernandez, the change has meant she will need to find another audiologist for her daughter.

Some doctors say the state is reassigning their patients to new offices and has created new administrative requirements that burden their practices, delay care for patients and slow payments from insurers.

“I hope this works out and is better for patients and more efficient for the state, but right now it’s been extremely challenging for all parties,” said Dr. Donald Luyre, a vice president of the Illinois Academy of Family Physicians and CEO of Elmhurst Clinic.

A state Medicaid official said the confusion is due to the speed and scope of the change — mandated by the Illinois General Assembly in 2011 — and not permanent flaws in the new system.

“Eventually, people will be able to get to the network that best serves them,” said James Parker, acting director of the Department of Healthcare and Family Services’ Division of Medical Programs.

The 2011 law required 50 percent of the state’s Medicaid population to be enrolled in managed care by Jan. 1 of this year. Illinois had enrolled about 1.6 million as of Feb. 1, said Department of Healthcare and Family Services spokesman John Hoffman. Parker has said the department plans to enroll 600,000 more this spring.

Officials have said the change will improve patient care and stabilize spending in a budget that is projected to grow to about $20 billion for fiscal year 2015. Managed care’s per-patient payments encourage providers to try to keep people healthy, which in turn should reduce costly emergency room visits and inpatient hospital stays, proponents of the system say.

But Sharon Post, director of the Health and Medicine Policy Research Group’s Center for Long-Term Care Reform, worries that the program’s rocky start might create lasting mistrust that could hinder managed care’s success.

“If it starts out feeling like this is a thing being done to me — either from the position of the patient or the Medicaid provider — then they’re not going to go along,” she said. “That really starts putting cracks in the foundation of reforming Medicaid.”

The state sends letters to Medicaid recipients listing plans available in their area — often more than a dozen — and informing them they have 60 days to pick one or be automatically assigned. So far, almost exactly half of managed-care patients have selected plans themselves, Parker said.

To help navigate the new system, the state is giving many patients an additional 90 days to switch plans after first enrolling, he said.

Patients who are auto-assigned are enrolled according to an algorithm that is meant to minimize disruptions to care, Parker said.

The algorithm keeps patients with their primary care physician, he said. If they don’t have one, the algorithm assigns them a plan based on more general medical claims data or, if they don’t have claims, usually to a plan with the lowest enrollment within 5 miles of where they live, he said.

But sometimes it doesn’t work as intended, doctors said.

Dr. Eddie Pont, an Elmhurst pediatrician who sits on the state’s Medicaid Advisory Committee, estimates his DuPage County practice has lost about 30 percent of its patients to an auto-assignment quirk.

Pont said the practice’s doctors decided to participate in a new type of care coordination group, called an accountable care entity, in which hospitals and providers take on the billing functions normally handled by an insurer. His practice joined Loyola Family Care, only to learn that the entity doesn’t cover every area in which his patients live. Those living outside the ZIP codes Loyola Family Care covers could not enroll.

His practice chose not to participate in any other health plans. Pont didn’t know about Loyola Family Care’s geographical limitation beforehand, he said, despite closely monitoring the managed-care rollout as an advisory committee member.

“Because things have moved so quickly, and with so little explanation, it’s been very frustrating and confusing for a lot of providers,” Pont said.

Incomplete information on plans and networks has required doctors and their staff to spend more time on administrative tasks, doctors said.

Plans cannot always verify that they cover a given patient, and providers get stuck proving the patient is in the plan before they can get paid, said Dr. Timothy Wall, a pediatrician and founder of Pediatric Health Associates.

Unlike traditional Medicaid, managed care requires patients to get a referral from their primary care physician to see a specialist. But which specialists are covered in each plan can be difficult to determine, doctors said. Wall said his employees sometimes spend up to two hours on the phone, plus added time on paperwork, to complete referrals.

Several doctors said the state could have better prepared them for the switch.

“We were not properly informed about all the inconveniences that were going to be faced,” said Dr. Walter D. Perez, owner of A to Z Pediatric and Youth Healthcare in Addison.

His administrators sometimes spend hours helping confused patients choose plans, Perez said. He estimates about 20 percent of his practice’s 1,000 Medicaid patients — most of whom are Hispanic — have been switched to another plan. He said he has gained new patients too, which shrinks his net loss.

At the start of the managed-care rollout, his office accepted only two plans, Family Health Network and Harmony Health Plan, Perez said. The state halted auto-assignments into both plans for a time because they were not meeting quality requirements, so assignments to his office stopped, he said. The sanctions have since been lifted for both plans, officials said.

State officials say they did all they could on a short timeline set by lawmakers to perform the state’s biggest change in health care in decades.

“Certainly we do understand that there is confusion out there, and I wish we would have had the time to do more education,” said Parker.

But he assigned some of the blame to providers, who he said resisted the change and were slow to join plan networks, despite knowing the 2015 deadline was coming.

“You can’t start educating people about what’s in a network until those networks are developed,” Parker said.

Kyle Holder, a 27-year-old mother of two who lives on the South Side of Chicago, said she has become an expert in recent weeks on managed care’s obscure world of plans and networks. She estimates she has spent around 20 hours trying to find a plan since she got a managed-care letter dated Jan. 9.

Some health plans list hospitals on their websites that aren’t in their networks, and some hospitals list plans that don’t include them, she said. Some listed plans or providers that accept only certain groups of patients, such as senior citizens, people with disabilities or childless adults.

Holder wants a plan that will let her keep her OB-GYN and will cover nearby Silver Cross Hospital in case she needs reproductive surgery or has another child.

Her situation became more complicated when her OB-GYN relocated to a suburb. She hasn’t been able to find a plan that covers both the OB-GYN and the local hospital.

“It’s just really frustrating, and it’s hard,” she said.

This article/medicare/disruptions-mount-as-illinois-shifts-medicaid-patients-to-managed-care/">article; first appeared on KFF" rel="nofollow">">KFF Health News and is republished here under a

/?republication-pixel=true&post=520952&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Illinois Turning To Insurance Agents For Obamacare Outreach

Wes Venteicher, Chicago Tribune — Fri, 16 Jan 2015 18:16:50 +0000

Keith Kelly knew buying health insurance would be complicated. So the 55-year-old Naperville man skipped the federal enrollment website and asked for help from someone he knew: an insurance salesman.

Kelly told insurance agent Robert Slayton about his underactive thyroid, his need for a chiropractor and other health specifics. After a briefing on deductibles, copays, drug costs and other insurance provisions, Kelly and his wife settled on a Blue Cross Blue Shield plan for which the couple pays about $700 per month.

Naperville, Ill., insurance agent Robert Slayton talks to potential clients Jeanne and Ralph Wysocki on Jan. 8, 2015. (Photo by Chuck Berman/Chicago Tribune)

“There are so many variables, and (Slayton) put them into easily understandable piles for us to go through and make our own informed decisions with his help,” Kelly said.

Insurance agents have so far played a limited role signing people up for Affordable Care Act insurance in Illinois, where the state has focused on federally funded navigators to inform people about their options and help them buy plans or enroll in Medicaid.

But with future funding for the navigator program uncertain, the state is expanding the role of insurance agents in its outreach efforts.

Get Covered Illinois, the state’s enrollment arm, is spending about $150,000 this winter to help 13 insurance brokerages pay for co-branded marketing materials, said Jennifer Koehler, Get Covered Illinois’ executive director. The site lists about 150 insurance agents who have completed state training courses in Medicaid and data security.

Unlike navigators, insurance agents can ask people specific questions about their health and then recommend a specific plan or insurer. Insurers pay agents a commission on plans sold, usually a percentage of the premiums.

Consumers should be aware that creates an incentive for agents and brokers to sell higher-priced plans, said Abe Scarr, director of the Illinois Public Interest Research Group.

“There are not necessarily enough protections in place to make sure that that’s not happening,” Scarr said.

Navigators are forbidden from accepting payments from insurers. Consumers also can compare plans on their own by using the website.

Agents say their commission on health plans in Illinois is around 6 percent of premiums — much less than they receive for selling other types of insurance. Sometimes insurers pay a flat fee instead.

The financial motivation for agents could help consumers in the long run by boosting the number of people with health insurance, said Barbara Otto, CEO of Health and Disability Advocates, a nonprofit that has been involved in state health initiatives.

“Who’s going to be enrolling populations after 2015, after 2016, after 2017? So we started investing in brokers,” Otto said.

For some health insurance shoppers, the specific recommendations agents can offer make it easier to pick a plan, said Slayton, president of Naperville-based brokerage Robert Slayton & Associates and a former president of the Illinois State Association of Health Underwriters.

“An agent can do the same thing (as a navigator), but at the same point in time they can advise the person based on their personal health on what they need,” he said.

Agents can also draw on their experience to help customers pick an insurer, Slayton said. For example, an agent could tell a customer that one insurer typically pays claims more reliably than another.

Agents receive no commission for selling Medicaid plans. They usually refer people who are eligible for Medicaid to navigators, several Chicago-area agents said.

The restriction on navigators recommending specific health plans is a product of negotiations between state officials and insurance agent groups before the federal marketplace came online, said Phil Lackman, executive vice president of Independent Insurance Agents of Illinois.

“We still believe, in the majority of cases, that consumers want the assistance of an agent or broker,” Lackman said, while acknowledging that in some parts of the state there are few licensed agents.

The federal government created and funded the navigator program to enroll people in private plans and Medicaid, the state insurance program for the poor and disabled.

Illinois is spending about $25.8 million in federal money on more than 900 navigators’ salaries for the open enrollment period ending Feb. 15. State health officials have applied for money to keep the program going at least through next year’s open enrollment, but it’s unclear how much they will receive, state spokesman Mike Claffey said.

Agents have traditionally helped small businesses manage health care plans and are well suited to reaching the working poor, a population that is important for the health law’s sustainability, said Otto, of Health & Disability Advocates.

Of the 900,000 working-age Illinoisans who became eligible for insurance through the Affordable Care Act’s federal marketplace, only about a quarter signed up during last year’s open enrollment period, according to an analysis of census data by Illinois Health Matters, the research arm of Health & Disability Advocates. About 63 percent of the 900,000 are employed, according to the analysis.

“If we want to reach that population, which is largely the working poor, we have to go to where they’re working. We have to be a little more innovative,” said Otto.

Most of the employed people who are eligible for marketplace plans work for small businesses or franchises, according to a Health & Disability Advocates report.

Insurance agents can help small businesses use the federal marketplace’s Small Business Health Options Program, known as the SHOP marketplace, or can help workers pick plans individually if their employer doesn’t offer insurance, the report suggests.

Making a profit from selling Affordable Care Act health insurance plans is difficult, said George Kleanthis, an agent with Woodridge-based Hartland Insurance Services, which started selling the plans in the current open enrollment period. But selling that coverage helps find clients who might be interested in life, auto, home and other types of insurance that pay higher rates, agents said.

Hartland has taken a similar approach to enrolling clients that navigators have taken — setting up tables at community events, going to churches and schools, holding town-square style meetings focused on health insurance.

“It’s a challenging business to be profitable in, but if you structure properly, and you’re able to scale a business, you can make money,” Kleanthis said.

This article/news/illinois-turning-to-insurance-agents-for-obamacare-outreach/">article; first appeared on KFF" rel="nofollow">">KFF Health News and is republished here under a

/?republication-pixel=true&post=516054&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Some Newly Covered Illinois Residents Still Struggle To Pay For Health Care

Wes Venteicher, Chicago Tribune — Fri, 05 Dec 2014 10:00:01 +0000

For Martha Gruberman, a 63-year-old resident of south suburban Steger, Illinois, obtaining health insurance through the Affordable Care Act hasn’t made it any easier to pay for routine medical care.

A plan she chose through the federal marketplace requires her to pay $5,000 toward medical costs before her insurer contributes anything. With an income of about $22,000, she doesn’t expect to hit that mark.

“I’m never going to use it,” she said. “I can’t use it. I can’t afford it.”

Gruberman and others who picked plans with the lowest monthly costs have found that medical care is still out of reach because of the plans’ high deductibles. As a result, many consumers with high-deductible plans are following old habits: delaying care or taking their needs to community health centers that have traditionally served the uninsured, local health administrators said.

“These people, even though they have access to some form of insurance, really do not have health care,” said Suzanne Hoban, executive director of Family Health Partnership Clinic, a free and reduced-cost clinic in Crystal Lake.

Officials have cited the number of people who signed up for private insurance last year as a measure of the federal health law’s success. About 217,000 Illinoisans signed up, exceeding federal expectations, and about 7.1 million Americans enrolled during the law’s first open enrollment period. But about 63,000 Illinoisans enrolled in low-premium bronze plans, which last year had a median deductible of $5,600 in the state and for 2015 have a median deductible of $5,750. Plans in the other categories — silver, gold and platinum — cost more per month but have lower deductibles and better benefits.

Administrators at free and charitable health care clinics in the Chicago area say they are adapting to new challenges posed by those among the newly insured who need help paying for care. The challenges are expected to grow next year.

Premiums for the cheapest bronze plans in Illinois are increasing by an average of 11 percent in 2015, according to state data. In the Chicago area, that means a 40-year-old will choose among bronze plans that have an average premium of $243 and a median deductible of $5,000, lower than the state median.

Annette Kopczynski, 62, of Huntley, signed up last year for a $6,000-deductible bronze plan with Blue Cross Blue Shield of Illinois. After tax credits, her monthly premium is $38. She said she sees a nurse practitioner at a reduced cost at Family Health Partnership Clinic because she cannot afford care through her insurance. She and her husband, who is on disability, pay about $25 per month toward the costs that accrue, she said.

“I don’t really go for tests or things that would cost, like physical therapy,” she said. “I would never do that. I’m just lucky. I’m mostly healthy. I just try to stay away from the doctors.”

Like other free and charitable clinics, Family Health Partnership traditionally served the uninsured. But this year the clinic changed its policy to accept people with insurance who can’t afford care, said Hoban, the clinic’s director.

“This is a paradigm shift for us,” she said.

CommunityHealth, a Chicago-based free clinic that serves 11,000 patients, is considering making a similar change next year, said Judith Haasis, CommunityHealth’s executive director.

“We’re going to consider serving individuals who are doing everything right, but when they look at the options won’t be able to access routine or medical care because the cost of accessing that care is going to be too great,” Haasis said.

“This is a paradigm shift for us,” she said.

CommunityHealth, a Chicago-based free clinic that serves 11,000 patients, is considering making a similar change next year, said Judith Haasis, CommunityHealth’s executive director.

“This is a paradigm shift for us,” she said.

CommunityHealth, a Chicago-based free clinic that serves 11,000 patients, is considering making a similar change next year, said Judith Haasis, CommunityHealth’s executive director.

While high-deductible plans sometimes contribute to poor health care decisions, they also force people to think more carefully about medical spending — a shift that could help contain medical costs and slow premium growth, another goal of the federal law, experts said.

“I can’t say it’s a direct cause and effect with high-deductible plans, but it does suggest to us that everyone in the system is doing a better job of managing care and managing the cost,” Connolly said.

All plans come with a set of free preventive services including cancer screening, immunizations and diet counseling. Since the health law passed, use of those services has increased, and young people are seeing primary care doctors more often and hospital admissions are starting to level off, Connolly said.

As consumers confront the nuances of health care, some patient advocates are looking for ways to simplify the way it is sold. Insurance companies have traditionally sold plans to businesses who offered their employees a few options, said Katherine Hempstead, who directs the Robert Wood Johnson Foundation’s work on health insurance coverage.

“This is a product that wasn’t designed to be sold to consumers, but now it’s being sold to consumers, and the design hasn’t changed that much,” Hempstead said.

The foundation is sponsoring competitions for developers to create tools that will help consumers select from the array of plans on the federal marketplace — there are 288 non-employer-based plans offered in Illinois this year. The tools would likely create algorithms that would narrow plans based on the medications people take, specialists they see and other personal health information.

“This is a product that wasn’t designed to be sold to consumers, but now it’s being sold to consumers, and the design hasn’t changed that much,” Hempstead said.

Tribune reporter Alex Richards contributed.

This article/insurance/some-newly-covered-illinois-residents-still-struggle-to-pay-for-health-care/">article; first appeared on KFF" rel="nofollow">">KFF Health News and is republished here under a

/?republication-pixel=true&post=509697&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Most Illinois Medicaid Patients Denied New Hepatitis C Drugs

Wes Venteicher, Chicago Tribune — Wed, 19 Nov 2014 10:00:49 +0000

Revolutionary new drugs are curing hepatitis C, halting a disease that can corrode the liver to the point of cirrhosis, cancer and death. But state restrictions on who can get the costly drugs are keeping them out of reach for some of the poorest patients.

Treatment with new drugs Sovaldi and Harvoni, the first reliable cures for hepatitis C, costs more than $94,000 per patient. The high price of Sovaldi drove Illinois Medicaid’s hepatitis C spending to $22 million for the fiscal year ending June 30, 2014, up from $6.7 million the previous year, according to the Illinois Department of Healthcare and Family Services.

Hepatitis C and Sovaldi

Facing higher costs, Medicaid officials stopped paying for any but the sickest patients to get the new drugs, drawing criticism from some liver doctors who have said the state is preventing them from properly treating their patients.

“There’s a difference between prescribing (hepatitis C) drugs and actually being able to get these drugs for our patients,” said Dr. Andrew Aronsohn, a liver specialist at the University of Chicago Medical Center. “It’s becoming a very complicated issue.”

The cash-strapped state faces a growing dilemma over how to balance public health and the spending of taxpayer dollars, as new specialty drugs emerge for hepatitis C and other sicknesses and more people are eligible for Medicaid under the Affordable Care Act.

In addition to limiting Sovaldi to the sickest patients, the Illinois Department of Healthcare and Family Services has set two dozen criteria for who can get the drug, including requiring that patients have no evidence of drug or alcohol abuse in the last 12 months and barring treatments not approved by the Food and Drug Administration.

Spending on hepatitis C treatment dropped from $1 million per week to about $200,000 per week after the department adopted the restrictions, said Dr. Arvind Goyal, the department’s medical director.

The state did not start keeping track of how many patients it denied Sovaldi until October, Goyal said. For the month of October, 43 of 50 patients who requested the treatment were denied, according to the department.

Thirty-six were denied because their livers were not in bad enough condition to qualify. The others’ livers were damaged enough but they failed to meet other criteria. From January through October, the state paid for 320 patients to get the new treatments, according to the department.

Goyal defends the restrictions on medical grounds, saying some patients may benefit by waiting for anticipated treatments that have higher cure rates and fewer side effects.

But patients’ livers are severely damaged by the time they qualify — some to the point of requiring an expensive transplant, Aronsohn and 17 other liver specialists said in an American Liver Foundation letter to the Department of Healthcare and Family Services in September.

“It’s a very strange conversation to say … I have a drug that’s very safe to cure this disease and I think it’d be great if you could get it, but I don’t think you’ll be able to get it because nobody wants to pay for it,” Aronsohn said.

More than 116,000 Illinoisans were estimated to have hepatitis C in 2010, according to a national hepatitis C index. The Centers for Disease Control and Prevention estimates about 3 million people in the U.S. have the disease, which is transmitted through blood.

Intravenous drug users are at the highest risk of contracting the disease, according to the CDC. Also at risk are people who had blood transfusions before 1992, when widespread screening of blood donors began. Symptoms range from abdominal pain to nausea and fatigue, and the disease can lead to complications including diabetes and skin cancer.

Past treatments for hepatitis C brought grueling side effects and offered low cure rates. Sovaldi, which came out in December, offers a cure of about 90 percent for the most common type of the disease when combined with other drugs. Harvoni, which the FDA approved Oct. 10, offers cure rates up to 99 percent and has few side effects. The Department of Healthcare and Family Services is in the process of developing new guidelines that will incorporate Harvoni, Goyal said.

All states that pay for the new drugs have restrictions on who can get them, said a spokeswoman from Gilead Sciences, the maker of Sovaldi and Harvoni. About half require that the treatment be approved by the FDA, while the others — including Illinois — further restrict treatment based on the condition of patients’ livers, according to Gilead.

“It’s been really difficult to get patients approved (for Sovaldi),” said Dr. Natasha Von Roenn, a liver specialist at Loyola University Medical Center. Von Roenn is one of the doctors who signed the American Liver Foundation letter.

Von Roenn said she has applied to the state three times for treatment for one Medicaid patient. The first time, she prescribed a treatment — a combination of Sovaldi and another pill, Olysio — that has proven effective but has not been approved by the FDA, and the state denied it. Then she requested Sovaldi and another drug. The state has not responded, she said. Recently she requested Harvoni, and is awaiting a response.

Even when patients are able to get the drugs, the state criteria create hurdles for successful treatment, Aronsohn said. Patients are only allowed to get two weeks’ worth of medicine at a time, and if they fail to refill their prescriptions, the treatment is canceled. A “once in a lifetime” provision in the criteria means that if treatment fails, the program will not pay for the patient to try again.

Some liver specialists do support the idea of limiting the drugs based on liver condition, considering the cost of the new treatments and the prevalence of hepatitis C.

Dr. Mahesh Patel, an assistant professor of internal medicine and infectious diseases at the University of Illinois at Chicago, said he would support limiting the new drugs to patients whose livers have developed the scarring that develops before full-blown cirrhosis.

“I don’t think there’s an emergency or an urgency to treat everybody,” Patel said.

But the state’s current criteria limiting treatment to patients with cirrhosis are overly restrictive, he said.

The American Association for the Study of Liver Diseases, which recommends treating all chronic hepatitis C patients, offers guidelines on restrictions. The association says patients who have developed liver scarring should be priorities for treatment, along with those who have cirrhosis and those with high risk of complications from the disease.

The standard 12-week treatment of Sovaldi and two other drugs costs $95,198, according to Gilead. Twelve weeks’ worth of Harvoni costs $94,500, according to the company. Some patients require as few as eight weeks of Harvoni, while others require up to 24 weeks.

State Medicaid programs have covered expensive specialty drugs in the past, but pharmaceutical companies have typically reserved such high costs for diseases with few patients, such as hemophilia, said Steven Miller, senior vice president and chief medical officer of Express Scripts, a national pharmacy benefit management company based in St. Louis.

“What changed when Sovaldi came to the market is this is really the first high-priced drug for an enormous patient population,” Miller said.

Express Scripts analyzed public-aid populations in each state to project spending if the states were to treat all their low-income hepatitis C patients, including prisoners. Illinois, at a projected cost of $2.3 billion, has the fifth-highest projected treatment cost. The top four are California, Texas, Florida and New York. The company estimates curing everyone in the country with state-funded health care would cost $55 billion.

A treatment for malignant melanoma released in September costs $150,000 per patient, Miller said. The company estimates a new high-cholesterol drug expected this summer will cost about $10,000 per patient, but the condition affects 71 million people, posing another potential challenge for public spending, he said.

“This new pricing regime is just not sustainable,” he said.

In Illinois, state law requires the Department of Healthcare and Family Services to restrict access to specialty drugs to limit costs. Goyal said the state created lawful restrictions and has accommodated patients, including paying for five people to get the Sovaldi-Olysio combination even though the FDA has not approved it.

“We have never lost sight of the fact that our role here is to serve our population in the best possible way that we can,” he said.

Federal law requires Medicaid programs to pay for FDA-approved drugs from certain pharmaceutical companies — including Gilead — regardless of cost, but allows states to restrict who can get them.

In some states, Medicaid officials have raised concerns that they could be sued by people denied treatment, said Matt Salo, executive director of the National Association of Medicaid Directors. Some directors are concerned that the FDA, the CDC or the Department of Veterans Affairs could become involved and force states to eliminate the cost-saving restrictions.

“On some level it’s hard to complain, because they’re actually creating needed cures,” Salo said. “… But with the price that it’s currently at, we simply can’t afford to provide it to everybody who needs it.”

This article/medicaid/most-illinois-medicaid-patients-denied-new-hepatitis-c-drugs/">article; first appeared on KFF" rel="nofollow">">KFF Health News and is republished here under a

/?republication-pixel=true&post=506739&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">

Illinois To Boost Medicaid Funding For Contraception

Wes Venteicher, Chicago Tribune — Thu, 21 Aug 2014 15:04:58 +0000

Medicaid patients in Illinois could gain increased access to contraception under policy changes proposed Wednesday by the Department of Healthcare and Family Services.

Health care providers would receive more money for providing vasectomies to men and birth control to women under the proposal, which also includes a possible new referral requirement for Roman Catholic providers and others that object to contraception.

The department expects to implement most of the proposed changes this fall, but department Director Julie Hamos said Medicaid will immediately start paying more toward the cost of long-term contraception at walk-in providers such as Planned Parenthood clinics.

Hamos said her department proposed the changes in part to address the recent Supreme Court decision that allowed some companies to exclude contraceptives from their employees’ insurance coverage on religious grounds. Oklahoma-based arts-and-crafts retailer Hobby Lobby, owned by evangelical Christians, sued over a requirement under the Affordable Care Act to cover contraceptives.

The court’s decision was of “extreme concern” to Gov. Pat Quinn and state health officials, Hamos said.

The new proposal affects residents covered under Medicaid, not by employers, but Hamos said the court’s decision brought new focus to the issue, spurring the department to announce the proposal quickly.

“It is an opportune time when women across the country are paying attention … that’s a time that we can really use that attention to focus on what’s available to them through Medicaid,” Hamos said. She noted that the change could help low-income women who shift between Medicaid and employer coverage as their employment situations change.

Unplanned pregnancies constitute a major cost among the approximately 1 million women of childbearing age enrolled in Medicaid in Illinois, Hamos said. About 3 million Illinoisans in all are enrolled, and the number is set to expand under the Affordable Care Act, commonly known as Obamacare.

Hamos said she could not provide cost estimates for the proposal but noted that 90 percent of Medicaid costs are being reimbursed by the federal government.

Expanded family planning has succeeded at saving money in other states, Hamos said, citing a Colorado initiative that she said cut teen birthrates by 40 percent from 2009 through 2013, reduced abortions and saved the state $42.5 million in 2010.

The Illinois proposal aims to coax more health care providers into expanding family planning services by increasing their reimbursement rates starting Oct. 1. Payments for vasectomies and intrauterine devices would be doubled. Hamos said the department is working with companies that manufacture IUDs to ensure they’re on health care providers’ shelves when needed.

The new policy also would increase reimbursement for nonsurgical sterilization kits, such as the device sold under the brand name Essure. Kai Tao, a senior policy adviser for the Department of Healthcare and Family Services, said the procedures are safer and less expensive than tubal ligation, the traditional surgical option, which Medicaid also covers.

In addition to the incentives, the proposal would prohibit “step therapy” rules that require a woman to try certain contraceptive methods before others. “It should be all about preventing and respecting the choice that she makes and how to do that,” Hamos said.

The Illinois department is prevented under federal law from requiring a health care provider to give patients information on contraceptives if it claims a “right of conscience” objection. Officials are weighing whether the state has the legal authority to add a new requirement to refer interested patients to institutions that do offer the information, Hamos said.

Representatives of local Catholic hospitals and a Roman Catholic business owner who filed suit over the Affordable Care Act’s contraception requirements did not immediately return phone calls.

The department, which worked with Planned Parenthood and other organizations on the proposal, is soliciting comments through Sept. 15 and expects to finalize the policy in the fall.

“This is a great way to give women access to the contraceptives they need in a timely fashion and have every contraceptive available to them,” said Pam Sutherland, vice president for public policy and education for Planned Parenthood of Illinois.

This article/medicaid/illinois-plans-to-boost-medicaid-funding-for-contraception/">article; first appeared on KFF" rel="nofollow">">KFF Health News and is republished here under a

/?republication-pixel=true&post=329036&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">