Article on IPADDU member Chris Propheter and Daughter

[Guest guest]

Hi all:

Great article on and Chris...wish I could reproduce the photo...

Ellen

State of change for our disabled residents

State revising care for area's blind, disabled, elderly

Comments

February 14, 2010

By ANDRE SALLES asalles@...

Propheter is bright-eyed, funny and eager to learn.

A 20-year-old graduate of St. North High School, Propheter is involved

in continuing education classes at Elgin Community College and holds a number of

internship jobs around town. She wants a good job and a full life.

» Click to enlarge image

Propheter (left) and her mother, , sit in the family's Geneva

home Wednesday. The Propheter family faces potential hardships,

Propheter says, if the state goes through with a planned pilot program to manage

care for people with disabilities.

(Tyler Stoffel/For Sun-Times Media)

RELATED STORIES

• Legislation would slow HMO pilot process

But Propheter also has a mental disability, one akin to autism. You may not even

notice it when you first talk to her, but as independent as she seems, she can't

fully take care of herself. She lives with her parents, Marc and , on

Geneva's west side and is dependent on them for the medical care and

developmental assistance she needs.

That's why the Propheters are so concerned about the state's new plan, unveiled

last week, to put thousands of Medicaid-eligible people in six counties under a

managed-care system. They know their daughter wants an independent life -- or at

least as independent as it can be -- and they're concerned that the state

program might not allow her to do that.

And they're not alone. It's being described as a trial period, but the state's

plan will bring sweeping change, and very soon, to nearly 38,000 people.

The Illinois Department of Healthcare and Family Services is looking to hire two

health maintenance organization (HMO) providers for the program. The five-year

contracts (with options for five more) would move every elderly, blind and

disabled Medicaid beneficiary to one of those two HMOs, which would then cover

their health, community and in-home care needs.

The state hopes to roll out this plan by Oct. 1. The pilot program would cover

Kane, DuPage, Will, Lake, Kankakee and suburban Cook counties.

Families concerned

Medicaid is a program that provides health coverage to low-income residents.

Medicaid covers the elderly, the disabled, those with severe medical needs,

those with breast and cervical cancer, and families with children and pregnant

women.

But rather than a pay-for-services model, like Medicaid, this new program would

see a tighter management of health services, with in-network care providers. It

would focus on preventative and follow-up care in an attempt to cut down on

duplication of services. And it would, state officials estimate, save about $200

million in health care costs by the end of the five-year trial.

Local families and social service providers, however, are worried that it would

do a few more things as well. They're concerned it would limit access to health

care and provide lower-quality care in the name of cutting costs.

And they're concerned that disabled people, like Propheter, might be

forced into situations that would not provide them with the individual attention

they need and would take them away from the health care providers they're

already comfortable with.

" We don't want our kids ripped out of environments they're familiar with because

it's more efficient, " mom said.

In place in Wisconsin

She knows what she's talking about. For years, Propheter has been the

legal guardian of another disabled woman, , who lives in Wisconsin.

(Propheter took guardianship when her aunt, the woman's grandmother, grew too

old to handle the job.) Wisconsin is one of 41 states with some form of

managed-care program.

, whose mental disability puts her at the level of a 5-year-old, had found

a stable living environment with another disabled woman and full-time

professional care. But after years there, Propheter said, the state separated

the two and moved into a home with six others and fewer staff to look

after them.

" They just said, 'we're no longer offering that kind of program,' " Propheter

said. " I've toured other homes in Milwaukee County (Wisconsin), and they're all

stuffed. Four to eight people in a home and never more than three staff. "

Funding in question

Lynn O'Shea has heard all the horror stories. As the director of the Association

for Individual Development, which serves 4,200 physically and developmentally

disabled people in six counties -- Kane, Kendall, DuPage, DeKalb, Will and

suburban Cook -- O'Shea knows just how individualized and specialized that care

can be.

And she knows just how under-funded those services are right now. AID has been

on the front lines of budget cutback battles over the past few years and went

into crisis mode last summer, when state legislators failed to pass a full

budget in time for the new fiscal year. Currently, the state is several months

behind in payments, not just to AID, but to everyone, to the tune of about $4

billion, according to Comptroller Dan Hynes' office.

She also knows that setting up an HMO program like this will involve an up-front

cost, and she's not sure where the money for that will come from.

" We're already under-funded so drastically, " she said. " How do people get better

care when there's less money to spend and more people to spread it around? "

State's reasoning

Jim has heard all the same horror stories. But , the deputy

administrator of medical programs at the Illinois Department of Healthcare and

Family Services, believes this program will not only save the state money, but

will provide better care for the people it covers.

The elderly, blind and disabled were chosen, said, because the state

spends $700 million a year on their health care. And, he said, studies have

shown that quite a lot of that money is spent inefficiently. There are too many

" acute episodes, " too many trips to the emergency room.

At present, when an elderly or disabled person is discharged from the hospital,

50 percent of the time they are readmitted soon after, he said.

That's where integrated care would come in. says those emergency room

visits and readmissions can be cut down with proper follow-up from a

managed-care company. And with an integrated system, information can more easily

be shared among doctors, hospitals and pharmacists, reducing duplicated

services.

Additionally, reducing the cost of health care could help lighten the waiting

list for state services. Currently, the Prioritization of Urgency of Need for

Services list has roughly 18,000 people on it.

Propheter has been on this list for years.

Community care

But beyond the cost savings, the goal is better care, said. To that end,

the state is including several financial incentives in the contract, ones that

he believes will nudge the HMO provider in the right direction.

For instance, he said, the contract will include a bonus for putting more

clients into community care and out of institutionalized care.

" We have continually asked the community to sit down with us and design

safeguards, " he said. " Tell us what the goal should be, and we'll put money

toward that goal. "

But all the safeguards in the world may not soothe medical and social service

providers, who believe that lumping every aspect of care for the disabled under

one model would be like shoving the proverbial square peg into the proverbial

round hole.

Hospitals have doubts

Kittoe, chief financial officer for Delnor Hospital in Geneva, sees this

program as an extra layer of bureaucracy that may delay and limit the medical

care his patients can receive. At present, doctors at Delnor are able to simply

order a test or procedure, but under an HMO plan, they would need pre-approval

for everything but emergency services.

" If you put another barrier to access in place, it's hard to fathom how this

population will navigate that barrier, " Kittoe said.

Additionally, he expects some cost-shifting to take place, since the HMO company

will need to be paid, leaving less money for the hospitals. The cost of

treatments and procedures may, as a result, go up, he said.

Tony auski is the executive director of The Arc of Illinois, an organization

that works with and advocates for the disabled. A lot of the services The Arc

provides are educational and social in nature, and auski doesn't know how

those will fit into an HMO model. The HMO, he says, will likely not be good at

managing those services since their expertise is medical.

The Illinois Hospital Association, which represents more than 200 hospitals and

health systems across the state, has several concerns about the plan, according

to s, senior vice president of government relations. Officials from

the IHA presented those concerns to a state House committee in January.

s believes the state is " trying to do too much with a needy population too

fast. " The HMO model may work on paper, he said, but that doesn't mean it will

be applicable to the Medicaid population. He would like to see the process

slowed down, and smaller trials launched, to prove that the concept can work

with the elderly, blind and disabled people it will cover.

" We don't have a good track record in this state with HMOs, " he said. " I don't

understand why they would take this kind of an approach. "

But said this plan is better than the alternatives -- more cuts to

services and service providers. He understands there is a trust issue between

the state and those who need those services, but he's asking for help to make

this program work.

" We could either cut eligibility, cut rates, cut services or spend more

efficiently, " he said. " No other alternative I've heard is a good alternative. "

Fears for her daughter

It is not set in stone that this system would spread statewide, either.

said his organization would study the five-year trial and see where else it

could work.

" The only way to overcome mistrust is to talk and talk, " said. " We have

very high hopes for this, we're taking bold steps and we want people to hold us

accountable. "

Propheter is certainly prepared to do that, she said. When her

daughter was born, was told that would never speak more than

two words at a time, would never learn to ride a bike, and would probably have

to live in a self-contained, bubble-like environment by the time she was 18.

It's two years beyond that now, and has come farther than anyone thought

she would. credits the individual, nurturing care she's been able to

give her for her entire life -- the medical professionals she's been allowed to

choose, the developmental assistance she's been allowed to help guide. And the

thought of losing that to a managed-care system terrifies her.

" If there were a vote on it now, I'd be a 'hell no,' " she said.

[Guest guest]

Hi all:

Great article on and Chris...wish I could reproduce the photo...

Ellen

State of change for our disabled residents

State revising care for area's blind, disabled, elderly

Comments

February 14, 2010

By ANDRE SALLES asalles@...

Propheter is bright-eyed, funny and eager to learn.

A 20-year-old graduate of St. North High School, Propheter is involved

in continuing education classes at Elgin Community College and holds a number of

internship jobs around town. She wants a good job and a full life.

» Click to enlarge image

Propheter (left) and her mother, , sit in the family's Geneva

home Wednesday. The Propheter family faces potential hardships,

Propheter says, if the state goes through with a planned pilot program to manage

care for people with disabilities.

(Tyler Stoffel/For Sun-Times Media)

RELATED STORIES

• Legislation would slow HMO pilot process

But Propheter also has a mental disability, one akin to autism. You may not even

notice it when you first talk to her, but as independent as she seems, she can't

fully take care of herself. She lives with her parents, Marc and , on

Geneva's west side and is dependent on them for the medical care and

developmental assistance she needs.

That's why the Propheters are so concerned about the state's new plan, unveiled

last week, to put thousands of Medicaid-eligible people in six counties under a

managed-care system. They know their daughter wants an independent life -- or at

least as independent as it can be -- and they're concerned that the state

program might not allow her to do that.

And they're not alone. It's being described as a trial period, but the state's

plan will bring sweeping change, and very soon, to nearly 38,000 people.

The Illinois Department of Healthcare and Family Services is looking to hire two

health maintenance organization (HMO) providers for the program. The five-year

contracts (with options for five more) would move every elderly, blind and

disabled Medicaid beneficiary to one of those two HMOs, which would then cover

their health, community and in-home care needs.

The state hopes to roll out this plan by Oct. 1. The pilot program would cover

Kane, DuPage, Will, Lake, Kankakee and suburban Cook counties.

Families concerned

Medicaid is a program that provides health coverage to low-income residents.

Medicaid covers the elderly, the disabled, those with severe medical needs,

those with breast and cervical cancer, and families with children and pregnant

women.

But rather than a pay-for-services model, like Medicaid, this new program would

see a tighter management of health services, with in-network care providers. It

would focus on preventative and follow-up care in an attempt to cut down on

duplication of services. And it would, state officials estimate, save about $200

million in health care costs by the end of the five-year trial.

Local families and social service providers, however, are worried that it would

do a few more things as well. They're concerned it would limit access to health

care and provide lower-quality care in the name of cutting costs.

And they're concerned that disabled people, like Propheter, might be

forced into situations that would not provide them with the individual attention

they need and would take them away from the health care providers they're

already comfortable with.

" We don't want our kids ripped out of environments they're familiar with because

it's more efficient, " mom said.

In place in Wisconsin

She knows what she's talking about. For years, Propheter has been the

legal guardian of another disabled woman, , who lives in Wisconsin.

(Propheter took guardianship when her aunt, the woman's grandmother, grew too

old to handle the job.) Wisconsin is one of 41 states with some form of

managed-care program.

, whose mental disability puts her at the level of a 5-year-old, had found

a stable living environment with another disabled woman and full-time

professional care. But after years there, Propheter said, the state separated

the two and moved into a home with six others and fewer staff to look

after them.

" They just said, 'we're no longer offering that kind of program,' " Propheter

said. " I've toured other homes in Milwaukee County (Wisconsin), and they're all

stuffed. Four to eight people in a home and never more than three staff. "

Funding in question

Lynn O'Shea has heard all the horror stories. As the director of the Association

for Individual Development, which serves 4,200 physically and developmentally

disabled people in six counties -- Kane, Kendall, DuPage, DeKalb, Will and

suburban Cook -- O'Shea knows just how individualized and specialized that care

can be.

And she knows just how under-funded those services are right now. AID has been

on the front lines of budget cutback battles over the past few years and went

into crisis mode last summer, when state legislators failed to pass a full

budget in time for the new fiscal year. Currently, the state is several months

behind in payments, not just to AID, but to everyone, to the tune of about $4

billion, according to Comptroller Dan Hynes' office.

She also knows that setting up an HMO program like this will involve an up-front

cost, and she's not sure where the money for that will come from.

" We're already under-funded so drastically, " she said. " How do people get better

care when there's less money to spend and more people to spread it around? "

State's reasoning

Jim has heard all the same horror stories. But , the deputy

administrator of medical programs at the Illinois Department of Healthcare and

Family Services, believes this program will not only save the state money, but

will provide better care for the people it covers.

The elderly, blind and disabled were chosen, said, because the state

spends $700 million a year on their health care. And, he said, studies have

shown that quite a lot of that money is spent inefficiently. There are too many

" acute episodes, " too many trips to the emergency room.

At present, when an elderly or disabled person is discharged from the hospital,

50 percent of the time they are readmitted soon after, he said.

That's where integrated care would come in. says those emergency room

visits and readmissions can be cut down with proper follow-up from a

managed-care company. And with an integrated system, information can more easily

be shared among doctors, hospitals and pharmacists, reducing duplicated

services.

Additionally, reducing the cost of health care could help lighten the waiting

list for state services. Currently, the Prioritization of Urgency of Need for

Services list has roughly 18,000 people on it.

Propheter has been on this list for years.

Community care

But beyond the cost savings, the goal is better care, said. To that end,

the state is including several financial incentives in the contract, ones that

he believes will nudge the HMO provider in the right direction.

For instance, he said, the contract will include a bonus for putting more

clients into community care and out of institutionalized care.

" We have continually asked the community to sit down with us and design

safeguards, " he said. " Tell us what the goal should be, and we'll put money

toward that goal. "

But all the safeguards in the world may not soothe medical and social service

providers, who believe that lumping every aspect of care for the disabled under

one model would be like shoving the proverbial square peg into the proverbial

round hole.

Hospitals have doubts

Kittoe, chief financial officer for Delnor Hospital in Geneva, sees this

program as an extra layer of bureaucracy that may delay and limit the medical

care his patients can receive. At present, doctors at Delnor are able to simply

order a test or procedure, but under an HMO plan, they would need pre-approval

for everything but emergency services.

" If you put another barrier to access in place, it's hard to fathom how this

population will navigate that barrier, " Kittoe said.

Additionally, he expects some cost-shifting to take place, since the HMO company

will need to be paid, leaving less money for the hospitals. The cost of

treatments and procedures may, as a result, go up, he said.

Tony auski is the executive director of The Arc of Illinois, an organization

that works with and advocates for the disabled. A lot of the services The Arc

provides are educational and social in nature, and auski doesn't know how

those will fit into an HMO model. The HMO, he says, will likely not be good at

managing those services since their expertise is medical.

The Illinois Hospital Association, which represents more than 200 hospitals and

health systems across the state, has several concerns about the plan, according

to s, senior vice president of government relations. Officials from

the IHA presented those concerns to a state House committee in January.

s believes the state is " trying to do too much with a needy population too

fast. " The HMO model may work on paper, he said, but that doesn't mean it will

be applicable to the Medicaid population. He would like to see the process

slowed down, and smaller trials launched, to prove that the concept can work

with the elderly, blind and disabled people it will cover.

" We don't have a good track record in this state with HMOs, " he said. " I don't

understand why they would take this kind of an approach. "

But said this plan is better than the alternatives -- more cuts to

services and service providers. He understands there is a trust issue between

the state and those who need those services, but he's asking for help to make

this program work.

" We could either cut eligibility, cut rates, cut services or spend more

efficiently, " he said. " No other alternative I've heard is a good alternative. "

Fears for her daughter

It is not set in stone that this system would spread statewide, either.

said his organization would study the five-year trial and see where else it

could work.

" The only way to overcome mistrust is to talk and talk, " said. " We have

very high hopes for this, we're taking bold steps and we want people to hold us

accountable. "

Propheter is certainly prepared to do that, she said. When her

daughter was born, was told that would never speak more than

two words at a time, would never learn to ride a bike, and would probably have

to live in a self-contained, bubble-like environment by the time she was 18.

It's two years beyond that now, and has come farther than anyone thought

she would. credits the individual, nurturing care she's been able to

give her for her entire life -- the medical professionals she's been allowed to

choose, the developmental assistance she's been allowed to help guide. And the

thought of losing that to a managed-care system terrifies her.

" If there were a vote on it now, I'd be a 'hell no,' " she said.