Psychcare I Florida Association of Health Plans

Transcription

1 Psychcare I Florida Association of Health Plans GENERAL SESSION I: HEALTH CARE COST DRIVERS September 6 th, 2012 PSYCHCARE psychcare.com September 6 th,

2 Introduction Beacon Health Strategies Industry leader providing comprehensive, behavioral health care solutions through clinically-driven, fiscally-responsible, quality programs Local & Specialized Solutions effective care management by working within local delivery systems and practices Beacon Comprehensive Behavioral Health Management in CA Psychcare in FL Autism Services Group in NJ Beacon UK in the United Kingdom PSYCHCARE psychcare.com September 6 th,

3 Beacon serves 7.7 million lives in 17 states, 70 health plans and 14 Medicaid programs MEDICAID MEDICARE MULTI-SECTOR PSYCHCARE psychcare.com September 6 th,

4 Autism Services Group, ASG Howard Savin, Ph.D. Founder and CEO Clinician, senior behavior health care executive, entrepreneur, and pioneer in behavior healthcare systems Co-founder of AGCA (1982), an MBHO in Philadelphia eventually covering 1.7 million lives in NJ, NY, MA, DE, MD, Carolinas and TX 15 years in the Developmental Disorders (DD) / Autism Spectrum Disorders (ASD) space Nearly 10 years as Sr. VP and Chief Clinical Officer for Devereux (nation s largest not-for-profit provider of child and adult behavior health services with a $400 million operating budget and 6,000 employees) Developed behavioral electronic clinical record system that significantly improved services for all stakeholders by making them measurable, accountable and outcomes driven Consultant to autism provider organizations assisting with business development and implementation of QM infrastructure PSYCHCARE psychcare.com September 6 th,

5 Autism Services Group I Managing Autism Benefits FAHP 2012 GENERAL SESSION I: HEALTH CARE COST DRIVERS PSYCHCARE psychcare.com September 6 th,

6 The Challenges to Managing Autism Benefits Managing the Unknown Practical Implementation Challenges Identifying the Right Infrastructure There is little actuarial data to show cost of care and meaningful outcomes. Many states cap the benefit, but parity may eliminate caps. How do you budget for a bottomless cost? Parents demand high levels of therapy but how does a payer determine and provide appropriate levels of care? Providers are generally not licensed and have little or no experience working with insurance payers. School systems are cost shifting to insurance payers. With significant industry transformation imminent, do payers have the resources, knowledge and time to properly develop programs to handle a single mandate for autism? Is it cost effective to build a solution for a single behavioral disease? AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,

7 Autism Spectrum Disorder Unmanaged Cost of Care Most recent studies estimate average cost of just ABA therapy from $25,000 to more than $125,000 per year, for children diagnosed at about age three until they enter school at age six to seven. THE ABOVE ESTIMATE DOES NOT INCLUDE THE FOLLOWING ADDITIONAL COSTS - for a child with autism: 40% more visits to a pediatrician 7X more psychiatric visits, except for age 2-4 then 13X visits Children with ASD have 4 times more inpatient hospital days 12X more psychiatric inpatient hospital days 40% higher medication costs Total medical costs are significantly higher for entire family with an autistic child AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,

8 Challenges in Care Management 1. Authorize an amount of services that are appropriate for each child diagnosed with autism, based solely on his/her needs, within the definition of the mandate 2. Reporting of quantifiable progress a. Narrative versus quantifiable data treatment goals must be quantifiable b. Lack of standardized format for reporting clinical data results in subjective interpretation 3. Distinguishing between early intervention, DDD, and school district obligations and insurance coverage for non-redundant, medical necessary care. 4. Lack of progress and denial of additional ABA services At what point? 5. Precise details of care management are essential in the appeals process. AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,

9 Real World Real Issues Parents and advocates are a very strong force. Easy to be the lead story on the 6:pm news. Families have historically received free care from public payers (early intervention and school systems, and DDD). Accountability has generally not been required by public payers. Provider re-imbursement rates are being rationalized at lower levels by insurance payers. Many providers have developed their own programmatic approach to autism care. Programmatic services do not meet the individual needs of each child. Payer s IT systems are generally not ready, e.g. cannot accept electronic claims for autism, use a single CPT code for all services or only approve a single service per day. More is better parent posture. My child is making progress so why are you authorizing fewer hours? AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,

10 ASG is a Bold New Approach to Autism Services One-stop Resource Peer to Peer Care Management Proprietary Platform Real-Time Encounter Data Comprehensive behavioral health services for payers, network providers and families dealing with autism Blend standardized service delivery approach with an accountable, outcomes-focused process Each comprehensive assessment is reviewed by our onstaff BCBA and ABA therapists to ensure appropriate care Invested in the design and delivery of its specialty care management platform that includes the measurement tools to truly manage functional capabilities of the population Highest quality of care, supported by measurable, statistical outcomes Ensure no overlap or redundancy of services by different payers ASG Goal: Bring modalities together under a single roof that delivers the highest quality of care and statistically-driven outcomes AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,

11 Data-Driven Approach to Care Management ASG is the quarterback of care ensuring no overlap or redundancy of services by different payers (insurance, school systems, state agencies and etc.). Medically necessary ABA therapy cannot be authorized in a vacuum what else is going on with this child? ABA School SLP DATA Primary Care Physician OT INTAKE DATA GATHERED: Diagnosis All therapies being delivered Medications IEP from school Speech, PT, and OT Neurology Other diseases Psychiatry PT AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 6 th 6, th 2012, 11

12 ASG s Care Management Dashboard AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,

13 FBA Reporting AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,

14 Data Reporting Entered by ABA Therapist after Each Encounter with the Child AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,

15 Lack of Progress ASG Peer to Peer Care Manager Gets Involved Hitting Spitting Kicking 10 0 Pinching 2/1/11 2/2/11 2/3/11 2/4/11 2/5/11 2/6/11 2/7/11 2/8/11 2/9/11 2/10/11 2/11/11 2/12/11 2/13/11 2/14/11 2/15/11 2/16/11 2/17/11 2/18/11 2/19/11 2/20/11 2/21/11 2/22/11 2/23/11 2/24/11 2/25/11 2/26/11 2/27/11 2/28/ Matching Phonics 10 Eye Contact 0 2/1/11 2/2/11 2/3/11 2/4/11 2/5/11 2/6/11 2/7/11 2/8/11 2/9/11 2/10/11 2/11/11 2/12/11 2/13/11 2/14/11 2/15/11 2/16/11 2/17/11 2/18/11 2/19/11 2/20/11 2/21/11 2/22/11 2/23/11 2/24/11 2/25/11 2/26/11 2/27/11 2/28/11 AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 6 th 6, th 2012, 15

16 Case Review for Each Child Making Progress MALADAPTIVE BEHAVIORS ARE DECLINING Hitting Spitting Kicking Pinching 1/3/11 1/5/11 1/7/11 1/9/11 1/11/1 1/13/1 1/15/1 1/17/1 1/19/1 1/21/1 1/23/1 1/25/1 1/27/1 1/29/1 1/31/ SKILLS ARE IMPROVING Eye Contact Matching Phonics /3/11 1/5/11 1/7/11 1/9/11 1/11/11 1/13/11 1/15/11 1/17/11 1/19/11 1/21/11 1/23/11 1/25/11 1/27/11 1/29/11 1/31/11 AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 6 th 6, th 2012, 16

17 ASG s Guidelines for Utilization Management ASG has built a nationwide reputation for delivering a rational, quality-driven system for authorizing and monitoring effectiveness and appropriateness of ABA treatment services. Toward that end, our approach to utilization management is grounded in the following principles: 1. Credentialing of a qualified provider network according to NCQA standards; 2. Ensure integrity of autism diagnoses; 3. Our clinical care model is based upon outcomes (i.e., skills gains and maladaptive behaviors reduced with improved overall functional status). After each encounter, the provider will enter the child s outcome for that session into our care management system. Better data regarding efficacy and outcomes means fewer hours, shorter tenure; 4. Our care management program is rooted in a peer-to-peer collaboration (i.e., the provider s BCBA and ASG s BCBA care manager); 5. Providers will be profiled according to specific criteria, such as ease of access, outcomes of care (i.e., percent of skills gains and maladaptive behaviors reduced over the treatment period) and family/caregiver satisfaction. 6. To ensure the best possible outcomes for each child, ASG requires parental involvement. Lack of active parent involvement and plateauing of demonstrated treatment gains over time will be the criteria for denial of service requests. AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,

18 THANK YOU I We look forward to working with you For more information, please contact: Howard Savin, Ph.D., CEO howard.savin@autismservicesgroup.com t Andy Fligor, SVP Strategy & Development andy.fligor@autismservicesgroup.com t AUTISM SERVICES GROUP PSYCHCARE autismservicesgroup.com psychcare.com September 66 th th,,