Sharron D. Matthews, Assistant Director,
Illinois Department of Healthcare and Family Services
In the fall of 2011, the Illinois Department of Healthcare and Family Services (HFS) researched client data for evidence of any possible over- utilization of medical services being paid by the State of Illinois Medicaid program. (The review and processing of payments for Medicaid Program services is a primary mission of HFS.)
Medicaid claims data initially indicated that approximately 2,400 individuals were cycling in and out of certain Metropolitan Chicago-based hospitals. These persons were entering through emergency rooms and being admitted for an average stay of 3 days receiving various treatments of detoxification services at a cost of almost $2,100 per stay (from 2009 to 2011) with no decisive indications of better health outcomes. Approximately 600 of these individuals were utilizing these services at a higher rate with 200 at a significantly increased rate in comparison to their cohorts.
Based on additional research, further analysis, and discussions among the Department's executive and senior management, it was determined that a change in policy was needed. Change was needed not only to reduce over-utilization but also to develop a more comprehensive and effective system of healthcare delivery for individuals challenged by alcohol and substance abuse in Illinois.
In the Spring 2012 session of the Illinois General Assembly, major legislation was passed to reduce the state's budget deficit. The bill included decreases in Medicaid spending through utilization management procedures, reduced rates, changes in eligibility and the inclusion of other policy changes to facilitate the implementation of state and federal healthcare reforms. The legislation was the Save Medicaid Access and Resources Together Act (SMART Act) - Senate Bill 2840, now Public Law 97-0689. This Act included a specific section on Detoxification Services paid for by the state's Medicaid program. The law specifically cited what actions the Department should employ to prevent further over-utilization of hospital-based inpatient detoxification services. It also authorized the initiation of a planning process for the development of recommendations for a more enhanced continuum of services to include both hospital and community –based providers working in a more coordinated collaboration to assist individuals towards sustainable recovery.
Two major actions were taken by HFS to comply with the SMART Act regarding detoxification services. The first, as of July 2012, individuals seeking inpatient hospital-based detoxification services paid by Medicaid were restricted to one pre-approved stay every 60 days, as compared to unlimited admissions and readmissions. (Note that individuals could then and still can at any time seek in-patient hospital care for medical reasons not diagnosed as detoxification only.)
The second, in August of 2012 HFS initiated the first in a series of internal management meetings to discuss the detoxification services planning process, staffing and timetable. Next joint agency meetings with DASA/DHS executive and senior staff were conducted to review client data, agree on the planning process and begin the identification of DASA providers and other stakeholders to recommend for Workgroup membership. Working together on this issue for the first time, both agencies committed to providing the staff and other resources needed to complete the planning for a more comprehensive and coordinated system for the delivery of services the State of Illinois could offer its alcohol and substance abuse challenged residents seeking assistance.
The legislative language was very specific as to whom the two departments were to engage in high level on-going participation throughout the planning process. In September 2012, separate work committee meetings were initiated with management representatives of the 11 most impacted hospitals and 33 recommended DASA service provider agency and stakeholders' organizations. Management of 4 HFS Coordinated Care Entities in Chicago were included later (November 2012) as they were awarded contracts.
You will note the use of the word "first" several times in this report because none of this work had been accomplished before by those prescribed to participate in the planning process as cited in the legislation. Working separately and together over an 11 month period, Workgroup members reviewed HFS and DHS/DASA client data; identified and discussed the major issues; shared current policies, practices and ideas for innovative approaches to treatment and new service delivery models; observed and reported on the impact of the new HFS policy changes in their service areas; and began to develop a working knowledge of and relationship with each other.
Eighty- six (86) individuals participated in the planning process from August 2012 through June 2013. These teams of experts working with state agency staff not only produced additional areas of recommendations but also developed a design for a model of an enhanced continuum of detoxification service delivery. The model will be initially tested and evaluated for replication through state funding of at least 3 different demonstration projects by June 2014 year.
What follows is a report on the planning process, and more importantly, its results of proposed recommendations for the next level of changes in policy, services and programs for the development of a continuum of comprehensive detoxification services leading to sustainable recovery for thousands in our State needing such vital support.