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Fine-Tuning Still Needed for Medicaid Managed Care
Thomas M. Anderson, MD
ISMS President
Thomas M. Anderson, MD

Illinois' transition of Medicaid patients to managed care organizations (MCOs) delivered a major shift to health care delivery. To date, 66 percent of Illinois' Medicaid beneficiaries are now in some form of managed care, and just this week Governor Rauner announced a plan to reconfigure the MCO program structure and increase participation to 80 percent. Medicaid managed care is here to stay.

The overall concept is a good one – help low income residents of Illinois obtain better care overall, increase access to preventive care in particular, and slow down the revolving door at the emergency room. But how is it really working out there where the rubber meets the road?

For starters, the state's initiative got off to a bumpy start, as it caused significant confusion among health care professionals and patients. It didn’t help that this transition began at about the same time as Illinois’ Medicaid expansion under the Affordable Care Act, which resulted in an estimated 625,000 additional lives covered under the Medicaid program.  

Many patients brought into MCOs had difficulties understanding the new system and the new rules for obtaining care. A patient's preferred physicians might not all be in the same MCO, forcing difficult decisions when choosing a plan. In many instances patients didn’t fully grasp the physician and hospital limitations required by the managed care model.

In advance of this transition, ISMS advocated that patients must be able to continue with their primary care physicians so that any disruption to existing doctor/patient relationships is avoided. As implementation progressed, we conducted a survey, which provided data highlighting many of the problems we’d been hearing about from physicians.

Our survey revealed administrative issues and inadequate communication have been especially frustrating for doctors.

Credentialing is one of the common administrative hassles. When applying to enroll with an MCO, physicians experience significant delays. The process is also quite cumbersome as some physicians may be required to credential separately with multiple MCOs within the Medicaid program. Most problematic is that there is a different process for each MCO.

Physicians and patients alike are also experiencing many problems with drug formularies. MCOs all have their own formulary and MCO drug manuals are hard to come by. Therefore, physicians have the burden of keeping track of what medications are included in various plans’ formularies.

Probably the biggest concern is that physicians do not even know who to contact at the MCOs!

In order to help the state’s most vulnerable patients, physicians need a streamlined process for credentialing, more consistent formularies and prior approval protocols, and a clear pathway to contact their MCOs. If and when these issues get ironed out, Medicaid’s major system redesign has the potential to be a successful chapter in its long-standing history.

There is some good news to report. ISMS has been in contact with the state, and progress is being made with the credentialing issue. The state has also developed a protocol for physicians to contact Medicaid when problems are not addressed by certain MCOs.

Additionally, the plan announced by Gov. Rauner this week includes reducing the number of MCOs in the Medicaid system. This could result in reduced hassles for physicians, which would be a step in the right direction. We look forward to hearing more details about this proposal, and ISMS remains committed to helping ensure the long-term viability of a responsible safety net for our state’s most vulnerable citizens.

I look forward to hearing from you. During my term, I can be reached at DrAnderson@isms.org.


The ISMS Advocacy team is interested in hearing about any problems you experience with the MCO initiative. Please email us with a brief description of your problem to help us track and monitor physician complaints.



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