Meeting the Autism Needs of. a commercial rollout. An Innovative Solution to Improve Health. July 2015

Transcription

1 Meeting the Autism Needs of Medi Cal Kids Lessons from a commercial rollout An Innovative Solution to Improve Health July 2015

2 The Impact of Autism Autism spectrum disorders are a group of complex brain development disorders that have a broad impact on children, families, communities and businesses. CHILDREN 1 in 68 children hld have autism 20 times higher than during the 1980s Autism generally appears by age three 40% of children with autism do not speak 19 medical conditions have been associated with autism FAMILIES COMMUNITIES BUSINESSES 50, families have a $137 billion in treatment 250 lost work hours per child diagnosed with autism costs per year person per year in caring annually 26 States require Applied for an autistic child $40k $60k in annual Behavior Analysis (ABA) $3k $5k in lost treatment costs per person as part of their essential productivity per person 40% of parents need help benefits per year bl balancing work and family 32 states have benefit coverage laws for Autism Parents of children with autism have higher rates of anxiety and depression responsibilities 46% of caregivers need help managing emotional and physical stress FINDING A SOLUTION Autism is complex but with the right treatment, care team, and resources families can be empowered to understand the complexities while helping to educate and inform others. Magellan is an industry leader, offering an array of services that help all of those impacted manage the challenges and costs of autism. CDC Data and Statistics on Autism, 2013; Autism fact sheet, National Autism Association, 2013; The autism society, 2013; Autism Speaks, 2013; National Business Group on Health: Therapies for Children with Autism Spectrum Disorders, May 2012, p.1. 2

3 What are we talking about when we say Autism Spectrum Disorders? (ASD) 3 of the pervasive developmental disorders in DSM IV Autistic disorder (AD) Asperger syndrome (AS) Pervasive developmental disorder NOS (PDD NOS) *These now included in DSM 5 as Autism Spectrum Disorder Epidemic or Re classification 20 years ago the prevalence was 1.5/200,000 Today 1/68 DSM did classify Autism with specific diagnostic criteria Today Autism is included in the category of Pervasive Developmental Disabilities o Autism o Asperger s o PDD NOS o Other Neurodegenerative CNS disorders Today we call it Autistic Spectrum Disorders o The addition of PDD NOS and Autism like disorders expands the population exponentially American Academy of Pediatrics Practice Guideline 3

4 Autistic Disorder (AD) AutisticDisorder (AD) Qualitative impairment in social interaction with at least 2 of the following: Impairment in non verbal behaviors in social interaction Failure to develop peer relationships Lack of spontaneous seeking to share emotions in relationships Lack of social or emotional reciprocity Qualitative impairments in communication with at least one of the following: Delay in or lack of spoken language Inability to sustain adequate conversation with others Stereotyped or idiosyncratic language Lack of spontaneous, varied play make believe or imitative Restricted repetitive and stereotyped patterns of behavior, interests, activities at least 1 of following: Preoccupation with oneoror morerestricted, stereotyped patternsof behavior thatareabnormalare abnormal in intensity or focus Inflexible adherence to specific, nonfunctional routines or rituals Stereotyped, repetitive motor mannerisms Persistent preoccupation with parts of objects Delays or abnormal functioning in at least one of following areas with onset before age 3: Social interaction Language Symbolic or imaginative play Disturbance not accounted for by Rett s disorder or childhood disintegrative disorder 4

5 Asperger s Disorder (AS) Qualitative impairment in social functioning at least 2 of following: o Impairment in use of multiple nonverbal behaviors o Failure to develop appropriate peer relationships o Lack of spontaneous seeking to share enjoyment, interests, achievements o Lack of social, emotional reciprocity Restricted repetitive and stereotyped patterns of behavior at least1 of following: o Encompassing preoccupation with one or more stereotyped and restricted patterns of interestabnormal in intensity or focus o Inflexible adherence to specific, nonfunctional routines or rituals o Stereotyped, repetitive motor mannerisms o Preoccupation with parts of objects Clinically significant impairment in important areas of functioning No significant general delay in language No significant delay in cognitive development or curiosity Criteria for PDD or schizophrenia not met Not part of the DSM 5 5

6 Pervasive Developmental Disorder NOS Severe, pervasive impairment in social functioning Impairmentin in verbal or non verbal communication skills Stereotyped behavior, interests, activities Criteria not met for other diagnoses such as: o o o o Specific PDD Schizophrenia Schizotypal personality disorder Avoidant personality disorder Not part of DSM 5 6

7 Etiology of ASD s Neurodevelopmental disorders, highly heritable Exact cause still unknown Involve multiple genes, much phenotypic variation May be associated with another medical syndrome (<10%) o Fragile X syndrome o Neurocutaneous disorders o Phenylketonuria o Fetal alcohol syndrome Environmental factors may influence development Advanced d age of parents Males predominate 7

8 Medical Conditions Associated with Autism Anxiety Bipolar Disorder Bowel disease Depression Fragile X Syndrome ADHD Mental Retardation Nonverbal learning disorders Motor clumsiness Obsessive compulsive disorder Tourette syndrome Seizures Sensory problems Tuberous sclerosis 8

9 Forms of Treatment

10 What therapies are effective? Identification of behaviors that are potentially harmful to child and others o Use behavioral modification techniques o May be by psychologist, ABA certified provider, OT, ST, PT Facilitate language o ST, traditional and total communication techniques Parent Training o No intervention is effective without parent training Special education program o Coordination of all modalities of therapy Specialized State/Federal Funding for Developmentally Disabilities o Respite care for family o Coordination of all treatment modalities 10

11 Applied Behavioral Analysis Some states mandate coverage Investigational vs. Evidence informed Small number of ABA certified practitioners Most BH practitioners have no training or familiarity with ABA ABA ranges from hours per week An array of teaching methodologies systematically applied to diminish inappropriate behaviors and promote desirable ones Multiple techniques, including discrete trial training and naturalistic teaching ABA programs integrate different strategies based on child s needs and target goals ABA methodologies incorporate data collection to monitor child s progress and evaluate effectiveness of the intervention 11

12 Common Elements Among Programs Individualized programs Systematic teaching Comprehensible/structured learning environments Specialized curriculum Functional approach to problem behaviors bh Family involvement Iovannone R, Dunlap G, Huber H, Kinkaid D. Effective educational practices for students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities. 2003;18:

13 High Touch\ High Relationship Approach to Improving Care, Health and Wellness, and Reducing Costs Combine our market leading clinical expertise to provide a holistic Care Management. Extensive support program of peers and health coaches available 24/7 access via web and mobile Social, educational and behavior change activities Referrals to community resources Caregiver Support Web based educational resources Online Family Peer Support Robust Resources *Depends on the clients current claims, prevalence and program structure. Prior authorization Comprehensive Benefit Concurrent review Management Outcomes monitoring for all levels of care Specialty Provider Network Enhanced Outreach & Care Coordination Ddi Dedicated tdspecialists ilit from Autism Center of Excellence facilitate communications between multi disciplinary care team member Condition education Link to community resources Licensed providers with expertise in treating ASD Providers certified in Applied Behavior Analysis (ABA) Use Skills clinical tool to improve quality of care Achieves an estimated return on investment from 2:1 up to 3:1.* 13

14 Enhanced Outreach and Care Coordination Provides much needed education, follow up and coordination of care through our Autism Center of Excellence Dedicated and highly trained autism specialist overseen by a certified behavioral analyst (BCBA) educates families with ASD in all aspects of the condition Actively engages the caregivers in their own care as well as the care for the child Follow up by providing linkages to community resources and facilitating communications between: Primary care Behavioral health providers Other care team members 14

15 Admission Assessment The child must have a current (within the last 18 months) diagnosis of autism spectrum disorder from an appropriately trained physician (pediatric, neurology, psychiatry or developmental) or psychologist, The assessment should include historical information and should include information from the child s caregivers and other treatment or educational providers in contact with the child. There must be a reasonable expectation on the part of a qualified lf treating health h care professional that skills and targeted behavior will improve. A functional assessment shall be completed by a qualified board certified bh behavioral analyst no less than every 18 months, including baseline information on the child s adaptive functioning. 15

16 Admission Treatment Plan Requirements The treatment plan, while based on the child s current functioning, should include a realistic evaluation of the child s long term potential and should delineate the milestones that will inform the continuation and discontinuation of services. The treatment plan must be built upon individualized goals. It must delineate both the frequency of baseline behaviors and the treatment development plan to address the behaviors. Its objectives must be measurable, based upon clinical observation, with outcome measurement assessment. It must be patient t tailored til and documented for the caregivers as well as the professional ABA team. The treatment plan must include care coordination involving parents or caregivers, school, state disability programs and others as applicable. Treatment should not seek to replicate services or care addressed in other environments, such as physical therapy, exercise programs, academic programs or recreational programs. The treatment plan must include a plan for ongoing gmonitoring across multiple areas of functioning, ensuring responsiveness to changes in the child s functioning. Adaptive skills must be measured at least every 3 months using a standardized adaptive functioning tool approved by Magellan. 16

17 Comprehensive vs. Focused Comprehensive Intervention is intended to be a treatment approach best incorporated into a younger child who presents with a wider range of deficits across multiple domains. A program with a Comprehensive Intervention approach would typically contain a higher rate of hours and consist of a longer duration of time in treatment. Focused Intervention is intended to be a treatment approach best developed for an individual that has shown success in a more intensive comprehensive intervention plan and has limited lingering issues, new acute issues, or is returning to treatment after previous discharge due to change in behavior. A Focused Intervention plan will consist of limited hours, and for a shorter duration to target the specific issue. 17

18 Focused Interventions Magellan will authorize medically necessary applied behavioral analysis, based on individualized goals, provided in a focused or comprehensive manner: Focused interventions will generally be provided for hours per week of direct treatment (additional authorization will be provided for direct and indirect supervision at 1 to 2 hours per 10 of direct care, as well as authorization for caregiver training) Focused intervention will be authorized when the patient needs to acquire skills such as communication, safety and self care Focused intervention will be authorized to reduce dangerous or maladaptive behavior Focused intervention will be authorized to introduce and strengthen more appropriate and functional behavior 18

19 Focused Intervention Case Study Dylan is a 16 year old boy who lives in Newbury Park, CA, with his parents and his 2 siblings. In April of 2000, Dylan was evaluated by a Neurologist. Dylan was diagnosed with Autistic Disorder (DSM IV TR ) Dylan also has since been Diagnosed with a seizure disorder and is treated by a neurologist. During this time Dylan has received various services as they relate to his Autism. He has been serviced by his local Regional Center as well as receiving services through his local School District via an IEP. Currently, a request has been made on Dylan s behalf due to a change in his behavior in recent months. Dylan presents with the following issues: Rude Behavior Public Masturbation Physical Stereotype Each behavior is reported to be occurring at a relative low rate, but are still causing social and safety issues for him. Given Dylan s success in previous programming and the reported rate of behavior Magellan agreed that a focused intervention plan was appropriate for Dylan to work on the reported behaviors and train his care givers on how to appropriately work with Dylan when he engages in targeted behavior. Therefore Dylan was authorized 2 hours per week of Direct 1:1 intervention. 4 hours a month of supervision and 4 hours a month of Caregiver training for 3 months. 19

20 Comprehensive Interventions Comprehensive services will generally be restricted to younger children who have substantial impairments in most or all areas of functioning; behavior is of such a severe nature that the child or those around the child are in imminent risk of harm; and are generally authorized as time limited The overarching goal of comprehensive intervention is to close the gap between a patient s level of functioning and that of a typically developing peer Comprehensive ABA of up to 40 hours per week is limited to treatment where there are multiple targets across most or all developmental domains that are impaired due to the child s autism. Comprehensive services are generally rendered when the patient is early in his or her development and is generally not intended to be applied to older children or adolescents who are often more appropriate for focused interventions Optimal treatment duration will vary by child, hl but literature generally supports total interventions (focused and comprehensive) in the range of 2 to 3 years or less of care. 20

21 Comprehensive Intervention Case Study Jennifer is a 2 year 9 month old girl who lives with her parents in San Mateo Ca. She was recently diagnosis with a Autistic Disorder (DSM IV TR ) by her pediatrician. Her parents are in the process of scheduling a comprehensive evaluation to confirm the diagnosis, as well as to rule out other possible issues. Jennifer is reported to be limited in her verbal ability. Her vocabulary consists of 5 words. Her primary form of communication is gestures, crying and tantrums. A ABAS 3 was conducted by a BCBA during her FBA and Jennifer was reported to present with scores in all domains in the Low to Moderate range. Jennifer presents with the following behaviors: Tantrums Non Compliance Elopement Aggression towards others Based on Jennifer s age, lack of previous programming, global delays, and severe behavioral issues, Magellan agreed with the treating BCBA that a comprehensive program was needed to address all the needs that Jennifer presented with. Therefore Jennifer was given a 6 month auth for 30 hours per week of direct 1:1, 12 hours per month of supervision, 10 hours a month of Caregiver Training 21

22 24/7 Resources to Promote Self Services and Continue the Benefits of Care Includes a comprehensive Online Autism Resource Center as well as connections to a wealth of community resources: Online resources Articles and research Applications Educational support Games and activities Video Training for Skill Development Externalsite and resources: Personalized kit Autism family services School community Community resources Advocacy groups 22

23 Our Clinical Program Produces Meaningful Results in Critical Functional Areas for Autistic Children. Standardized Vineland Scores Intake 1 year Communication Daily Living Skills Socialization 23

24 Special Medi Cal Considerations

25 Department of Health Care Services Report Medi Cal Clto begin managing ABA programming for their members that are managed by the Regional Centers: An estimated 76,000 children under the age of 21 enrolled in the Medi Cal program have autism Fewer than 1200 of these children are actively engaged in services at this time Far below expected levels 24 of California's 58 counties have provided no behavioral health treatment under Medi Cal managed care plans; 18 counties have fewer than 11 cases per county The remaining 16 counties provide BHT services to 943 Medi Cal managed care children, an average of roughly 59 children per county. 25

26 Provider Network Requirements All commercial plans require a BCBA, Occupational Therapist, Speech Therapist or a Licensed Mental Health professional to fulfill supervision hours for all ABA cases. Most Regional Centers in CA allow for a Masters level individual to provide all case supervision for both Lanterman programs, (over 3 with a Diagnosis) and Early Start Services (under 3 may or may not have a diagnosis) and don t require a BCBA to interact with the case. Some CA Health Plans as well as Tri Care allow for amiddle tier supervision model Currently there are approximately 3,100 BCBAs in the state of California and there are some parts of the sate that have waiting lists due to lack of BCBAs Currently no clear guidance in SB946 that allows a mid level supervisor model If Medi Cal plans only allow a BCBA to supervise it will place an even greater burden on the Provider groups. 26

27 Registered Behavioral Technician (RBT) The RBT is a paraprofessional who practices under the close, ongoing supervision of a BCBA, BCaBA, or FL CBA ( designated RBT supervisor ). The RBT is primarily responsible for the direct implementation of skill acquisition and behavior reduction plans developed by the supervisor. The RBT may also collect data and conduct certain types of assessments (e.g., stimulus preference assessments). The RBT does not design intervention or assessment plans. It is the responsibility of the designated RBT supervisor to determine which tasks an RBT may perform as a function of his or her training, experience, and competence. The designated RBT supervisor is ultimately responsible for the work performed by the RBT. The following are the eligibility requirements for the RBT credential. Be at least 18 years of age Possess a minimum of a high school diploma or national equivalent Successfully complete a criminal background registry check at the time of application (no more than 45 days prior to submitting the application) Complete a 40 hour training program (conducted by a BACB certificant) based on the RBT Task List Pass the RBT Competency Assessment administered by a BACB certificant Starting December 14 th 2015 Pay a $50 application fee (annual renewal fees are $35) 27

28 Summary Autism is a complex disorder that can impact various areas of development in an individual, most notably communication and social interactions. Rates of cases are steadily increasing world wide as education, understanding, and better screening tools have been developed. The diagnostic process is a key factor in the overall success of treatment for an individual. id A diagnosis i should ldbe given by a MD or Psychologist tthat t has a specialty ilt in Autism. The individual conducting the assessment should have access to various professionals in order to rule in or out other possible conditions. Many treatment modalities are present in the treatment of Autism. The most scientifically supported modality is ABA. Magellan has modified the manner in which care for an ABA program will be reviewed. Based on clinical information a case will be authorized for either Comprehensive or Focused intervention. Magellan will also place a greater emphasis on Caregiver involvement, training and transition. Based on clinical information, authorizations will be 3 to 6 months in length. 28

29 What Magellan Can Do for You A partner who can be ready immediately Extensive background din implementing i autism benefits across Health Plans, Employer Groups and Public Sector A robust network across the United States with strong partnerships with well respected Demonstrated credibility Magellan well established Member of the DMHC s Governor s task force implementing SB946 as well as advisors to many states as they planned to go live with benefit Demonstrated clinical expertise Magellan has a Center of Excellence in San Diego lead by a Board Certified Behavioral Analyst and staffed with licensed care management staff A one of a kind program to support caregivers to improve outcomes, reduce suffering and promote savings High satisfaction ratings from members 95.2% agreed that they received individualized treatment plans to meet their child s specific needs An effective cost efficient model from day one. Magellan consistently provides a return on Investment (ROI) Source: Magellan client analysis, 2012 First to market with an Autism program, Magellan continues to be the leading choice for Autism among payers. 29

30 Thank You This presentation may include material non public information about Magellan Health Services, Inc. ( Magellan or the Company ). By receipt of this presentation each recipient acknowledges that it is aware that the United States securities laws prohibit any person or entity in possession of material non public information about a company or its affiliates from purchasing or selling securities of such company or from the communication of such information to any other person under circumstance in which it is reasonably foreseeable that such person may purchase or sell such securities with the benefit of such information. The information presented in this presentation is confidential and expected to be used for the sole purpose of considering the purchase of Magellan services. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential. The attached material shall not be photocopied, p reproduced, distributed to or disclosed to others at any time without the prior written consent of the Company. 30