Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
35 Cards in this Set
- Front
- Back
|
Categories of Mental Disorders
|
• Adjustment disorders (e.g., situational stress)
• Anxiety disorders (e.g., panic disorder) • Childhood disorders (e.g., autism) • Eating disorders (e.g., anorexia) • Mood disorders (e.g., major depressive disorder) • Cognitive disorders (e.g., dementia) • Personality disorders (e.g., antisocial personality disorder) • Psychotic disorder (e.g., schizophrenia) • Substance-related disorders (e.g., alcohol/drug dependence) |
|
|
Need for behavioral health benefits
|
Mental illness is #1 cause of disability in U.S., Canada and western Europe.
Alcohol consumption accounts for 40% of industrial fatalities, 47% industrial injuries Behavioral benefits are the least understood, most poorly compensated component in benefit packages |
|
|
Misperceptions re: Behavioral Health benefits
|
most people think their medical plans cover behavioral care adequately. Most plans limit bennies to emergency assessment and crisis coverage. EAPs focus on workplace productivity, limit emotional counseling visits.
|
|
|
The early years of mental health care bennie
|
Prior to 40's, treated in State mental hospitals.
After WWII, hospitalization for MH insured at the same level as non-psychiatric bennies. Insurers limited outpatient coverage because treatment was subjective and continued for indefinite time. |
|
|
Growth of Managed Care
|
HMO Act of 1973 promoted and set minimum standards for HMOs --> required coverage for 20 outpatient MH visits/yr for ER assessment, crisis intervention.
MH coverage extremely limited under HMOs in 80s --> hospital MH restricted to 30 - 45 days per mental illness or 30 to 60 days per year. Outpatient MH limits were dramatically lower than other medical treatments --> common 1000 annual max, w/ max reimbursement per visit set at $25 to $40 --> coinsurance varied dramatically |
|
|
Behavioral Health Care Carve Out
|
Separates MH and CD from other med coverage --> services usually under separate MBHO contract
|
|
|
Design of behavioral Health Carve Out
|
Potential for significant savings because
• Usually managed by firms that specialize in behavioral health treatment • Allows large, self-funded employers to offer same MH benefits across all health plans offered • Allow a health plan to minimize adverse selection |
|
|
Growth of EAP
|
Confidential resource providing information & referral for emotional counseling
**Used re family conflicts, relationship issues, job stress, substance abuse, financial difficulties, etc. Earliest EAPs (1950s) focused on substance abuse; evolved to cover many concerns & HR support **Generally considered a low-cost high-return tool for enhancing worker productivity |
|
|
Psychotropic Medication Management
|
Drugs that affect psychic function, behavior or experience.
Part of med coverage, generally administered by PBMs **Account for a significant part of overall health costs, because they treat chronic mental illnesses **Current fractionalized system prevents optimum management of these medications **70% - 80% are prescribed by PCPs, not MH specialists -MBHOs don’t manage Rx benefit, but are responsible for managing behavioral care -MBHOs often not aware if psychotrophic medications are appropriately prescribed & taken -HIPAA privacy regulations make it more difficult to get complete information |
|
|
The Mental Health Parity Act
|
Enacted to establish parity between MH & other group health benefits (self-funded or insured, HMOs).
**Annual and lifetime dollar limits on MH cannot be lower than for medical & surgical coverage **OK to limit MH in terms of inpatient days, outpatient visits, Rx differently **OK to have separate and/or higher dollar deductible for MH care Does not apply to the individual insurance market, only to group plans. Applies to group plans only if they offer MH coverage and have more than 50 workers Does not address chemical dependency/substance abuse Plans may ask to be excepted from Act if implementation would raise premium costs by more than 1% **Only a few plans have filed for this exception. |
|
|
Federal & State Parity Legislation
|
At least 35 states have their own form of MH parity laws
Typically, state laws incorporate more inclusive parity coverage than federal Act Many require parity for substance abuse / chemical dependency |
|
|
Managed Behavioral Health Market
|
Size: 250 mill insured Americans, 66% enrolled in some MBHO, plus those covered by HMOs w/ MH bennies
Composition: Most BH bennies sold in US are purchased by large groups that buy comprehensive health care --> smaller the group, the more likely to buy integrated part of general health plan Sales Environment: - Large brokerage and consulting firms - Large MBHO sales force - Health carrier sales force |
|
|
Reasons for MBHO mergers & acquisitions
|
• Payers demand greater capital reserves to pay providers more quickly, cover risk more adequately
• Greater investment in managed info systems to meet accountability & accreditation requirements • Premium and capitation payments are stagnant, so MCOs aren’t seeing increased revenues in existing businesses • Costs of developing public procurement bids, esp. for statewide contracts, can be large 75% of market is controlled by 10 largest companies; 50% by just 3. |
|
|
Behavioral Health Care Plan Features
|
• Vast majority of plans cover inpatient and outpatient treatment
• ~ 50% cover intermediate treatment (e.g., residential treatment, partial (day) hospitalization) • ~ 60% cover intensive outpatient services (psych rehab, case mgt, wraparound services for kids) • Many include parity (severe mental illness) benefit that specifies disorders per state parity law |
|
|
Behavioral Health Care Plan Variables, ERISA and HIPAA
|
Variables: Typical to cover 30 MH inpatient days per year and 20 MH outpatient visits per year
80% of employees have less generous limits, copayments, coinsurance for inpatient MH than medical ERISA: States may not regulate benefits of multi-state employer-funded plans, 9 ½ million federal employees HIPAA: Protects sensitive patient info gathered during behavioral treatment |
|
|
MBHO Funding Arrangements
|
• Fully insured
o Shared-risk arrangements • Administrative services only (ASO) |
|
|
Fully Insured Arrangements
|
MBHO assumes financial risk for providing MH services, pays claims
If overall plan costs > expected levels, MBHO must absorb the increase Purchaser pays MBHO a predetermined, fixed premium ~ 3% to 6% of medical plan’s premium for fully-insured, full-risk behavioral plan, excluding EAP Primary cost drivers for full-risk funding arrangement: • Utilization rates • Unit costs for practitioner and facility care |
|
|
Shared Risk Funding Arrangements
|
variation of fully-insured arrangement
Purchaser assumes financial risk for paying claims up to a certain amount MBHO pays (all or a % of) claims above that amount **Premiums based on projected claims cost **If claims are below the specified amount, balance could be either: • shared by MBHO and employer-client • refunded to employer-client |
|
|
Administrative Services Only (ASO) - Self Funded (Insured)
|
MBHO will be paid a fee to handle medical mgmt, UR, claims payment, other admin. functions
Purchaser (plan sponsor / employer) assumes financial risk of providing health care to its members **The larger the group, the more likely it is to self-fund, because • it can spread risk across greater number of employees and • it has a budget large enough to absorb the risk. Key advantage is that the employer can offer same benefit across state lines ERISA exempts self-funded plans from most state insurance laws & regulations |
|
|
EAPs
|
Confidential, short-term counseling service to help employees & family with personal problems
**Intent is to intervene in stressful situations that could otherwise impact job performance **Provided by MBHOs, stand-alone EAP firms, or work/life companies. Originally focused on substance abuse problems, evolved to comprehensively support family issues **May include proactive prevention and health & wellness programs **Generally refer to other professionals or agencies for expert and longer-term help **May provide HR support: mgmt consultation, on-site seminars, stress mgmt after catastrophes Utilization averages 6% to 7%, but rises to 7% to 10% if work/life programs added |
|
|
EAP Types
|
1) EAP
Full-service EAP offers set number of free face-to-face counseling sessions (typically 3 to 8 per year) Counselors are community-based licensed MH professionals under contract to MBHO or EAP firm May also provide free information or referral to other specialists for work/life concerns 2) Work life benefits Instead of full-service EAP, may offer only telephone or web-based access to EAP counselors. 3) Advantages of an EAP Easy access, less stigma than MH visit. Cost-effective for early resolution, saves $5 to $16 per $1 cost. |
|
|
Requirements for an Effective Behavioral Health Program
|
Provide integrated mental health/chemical dependency benefit with inpatient & outpatients service + EAP
Effectiveness depends on: • Employee & employer awareness of programs’ services and their value • Appropriate use of benefits • How well the behavioral vendor and its network providers prevent & manage costly disorders Often, employee does not really recognize what the scope of problem is and needs guidance to recognize it. |
|
|
Behavioral Health Providers
(Specialty Network) |
Typically includes:
• Individual (solo) practitioners • Multi-specialty group practices (clinical psychologists, socials workers, masters-level therapists, psychiatric nurses, psychiatrists) • May also include medical doctors who specialize in addictionology, and developmental behavioral pediatricians |
|
|
Inpatient, Day and Outpatient Treatment
|
Inpatient: acute treatment needs; individuals unable to care for themselves.
Day (or partial hospital) treatments: intensive during daytime, but patients go home overnight Outpatient: can be intensive for patients who need more than weekly therapy, but fewer hours than partial/day facilities offer. |
|
|
Behavioral Health Provider(Credentialing)
|
MBHO verify practitioner credentials before allowing them into network
**Education, board certification, work history, liability insurance & malpractice coverage, etc. **Generally, MBHOs recredential every 2 or 3 years to ensure quality standards are maintained. |
|
|
Behavioral Health Provider
(Customized Networks) |
MBHO often custom-build networks to suit a group's geographic, cultural, language, other needs.
** members prefer a choice of providers across a broad spectrum of care. |
|
|
BH Provider Pay arrangements
(Fee for Service) |
Most widely-used payment arrangement.
Pay for each service at set contract rate (negotiated or discounted in exchange for volume). MBHO manages length & intensity of services through utilization & quality controls. |
|
|
BH Provider Pay arrangements
(Capitation) |
Fixed payment per member per month for defined services.
Provider assumes financial risk, so more likely agreed to by group practices rather than solo. |
|
|
BH Provider Pay arrangements
(Per Diem and case rates) |
Most common arrangement for facilities and organized programs.
Per diem: negotiated daily rate for all inpatient services Case rate: capitated arrangement for individual cases (uncommon except in CD cases) |
|
|
MBHO Cost Containment
|
1. Care Access
2. Predictive Modeling and Risk Management 3. Performance Measurement 4. Case Mgmt 5. Utilization Review and Management 6. Outcomes Mgmt 7. Coordination of Care 8. Depression Disease Mgmt Programs 9. Substance Abuse Relapse Programs |
|
|
National Committee for Quality Assurance (NCQA)
|
Largest accrediting body for HMOs, accrediting MBHOs since 1997.
MBHOs must meet quality standards (e.g., access, triage, network adequacy, communication w/ PCP) Full accreditation effective for 3 years; also 1-year and provisional levels of accreditation |
|
|
Utilization Review accreditation Commission (URAC)
|
Accrediting health plans and PPOs since 1996
MBHOs subject to Core Accreditation, and Health Utilization Management Accreditation **Core includes organizational structure, staff qualifications, training & management, oversight of delegated activities, quality mgmt, consumer protection **HUMA ensure clinically sound UM, respect for patient & provider rights, confidentiality, reasonable payment guidelines, compliance with USDOL claim regulations. |
|
|
Joint Commission on Accreditation of Healthcare Orgs (JCAHO)
|
Expanded from hospital accreditation to behavioral health in 1972, to MBHOs in 1994.
**1,600 behavioral health organizations and 25 plans/integrated delivery systems accredited. **Must provide services to defined population, offer comprehensive or specialty services, have centralized integrated structure as well as contract/manage care delivery sites (practitioner offices) |
|
|
Broadening Care Access
|
Innovative approaches to meet the needs of mental health patients:
• Proactive disease mgmt programs operating on several fronts ○ Working with employers to reach members at their workplace ○ Working with health plans to identify those taking psychotropic drugs ○ Reaching out to patients with other illness (diabetes, cardiac conditions) likely to suffer MH problems • Outreach to people who want treatment, but need help finding access or best therapist for them • Ways of delivering therapy for best accessibility & cost-effectiveness ○ Patient with mild/moderate distress can benefit from coach counseling via phone or internet |
|
|
Productivity
|
MBHOs need to demonstrate that they deliver benefits that result in increased workplace productivity.
|
