Urgent Care Should ‘Watch and Learn’ as Illinois Deals with Medicaid Headaches

Illinois is not unique in wrestling with Medicaid managed care plan problems, but the situation there seems to have reached a boiling point and can serve as a cautionary tale for urgent care stakeholders across the country. Health system officials there complain that getting providers approved by Medicaid managed care plans has taken anywhere from 6 months up to a whole year. Prior authorizations and reimbursements have been similarly slow in coming, making it so cumbersome to do business that some have quit dealing with the state Medicaid system altogether. This has created a ripple effect for Medicaid members, of course, who now have a shrinking pool of providers to choose from. Amerigroup, AmeriHealth Caritas, and UnitedHealthcare claim they’ve lost a combined $450 million, roughly, since the Medicaid managed care program began in 2016. Most recently, Illinois asked the federal government for $225 million to help make up for its Medicaid losses. Not surprisingly, Gov. Bruce Rauner has said he wants to revamp the program and cancel any existing contracts 2 years ahead of their expiration—an unprecedented move, according to some experts. Beyond Illinois, about 73% of the nation’s Medicaid beneficiaries—more than 50 million people—are covered by private plans, according to research firm PwC. Some states, Ohio and New Jersey among them, have outsourced management of their Medicaid programs to third-party providers. Fallon Health, a Massachusetts-based plan ranked near the top of the NCQA Medicaid ratings, uses predictive modeling to spot beneficiaries who overuse hospital emergency departments. The plan then connects those patients with a care coordinator. That model bodes well for urgent care providers, who are uniquely positioned to take in patients who need immediate care for nonemergent illness and injury. It is important to note that the problems in Illinois (and elsewhere) do not reflect poorly on managed care, which has proven itself to be a cost-effective conduit to high-quality care—again, speaking to the value of urgent care, as well—when there is a high level of care coordination.