Mc- Chpt 25 Behavioral Health (Bh)

Front 1

Behavioral Health Care includes:

Back 1

 mental health
 substance abuse
 serious mental illness

Front 2

Types of facilities/treatments/programs:

Back 2

 outpatient
 12-step
 partial hosp.
 rehab/detox clinics
 crisis houses
 24-hour security
 emergency phone hotlines

Front 3

Why is it critical for MCO's to offer BH these days?

Back 3

 Public willing to get BH care
 Gov’t parity mandates
 Public demand
 Er demand
 focus on clinical outcomes, not just costs
 BH care saves costs in the long run

Front 4

Difficulties in Managing BH
(“Why Does BH Require Incisive Management”)

Back 4

 All the reasons why it’s “Critical For MCO’s To Offer It” (from above)
 BH is chronic, lifelong problem
 Labor-Intensive (as opposed to medical, which is technology-intensive)
 No standardized protocols
 Hard to determine if “medically necessary”
 shrinking resources
 Changing clinical practices can cause unintended consequences.
 Informatics problems in BH (this applies to Health Care in general, too)
 fragmented industry
 lack of information standards
 incompatible data
 Data systems were not created for BH use.

Front 5

Paradigmatic Shifts in Managing BH (or "Goals in modern BH Mgmt")
I.e. the Old Paradigm vs. the New Paradigm

Back 5

 OLD: wait for patients to come for help
 NEW: Proactive targeting and treatment

 OLD: Alcoholics not covered
 NEW: Proactive targeting of alcoholics

 OLD: carve-out
 NEW: capitated

 OLD: focused on individual patients
 NEW: target a defined population (a.k.a. "shift towards systems planning"; "shift to a systems paradigm")

 OLD: focus on cost-reduction
 NEW: focus on clinical outcome (long-term cost-savings; patient satisfaction)

 NEW: Quicker response
 NEW: Follow-up and continuity of care
 NEW: Gov’t mandates
 NEW: Longitudinal, coordinated mgmt
 NEW: Examination of intended and unintended consquences of cost strategies

Front 6

BUILDING A BH PROVIDER NETWORK (CHOOSING PROVIDERS, MAINTAINING THE NETWORK, ETC.)

Back 6

 Size and Scope:
 30 mins driving time
 1 BH provider to 1000 members. 30% psychiatrists.
 Provider Selection Criteria:
Providers must:
 have good clinical outcomes (goal-focused)
 have multidisciplinary knowledge
 use peer support
 use community resources

Front 7

THE BEHAVIORAL HEALTH CARE MGMT PROCESS

Back 7

 All of the "NEW's" from “Paradigms,” above
 Use multiple clinical pathways
 assess the type and intensity of services needed
 Use the "least restrictive" but still-effective method
 Use social support to reduce relapses
 obtain medical cost offsets
 BH often comorbid with medical problems

Strategy:
1. Identify high-risk individuals.
2. Which of them have BH problems?
3. Actively target those individuals.

 compare expenditures to resources
 Use integrated Dual Diagnosis programs
 when someone is mentally ill and has a drug problem
 very high-risk patients
 noncompliant
 disproportionate cost

Recommended Strategy:
 Routine surveillance
 cross-training of providers

 Use Coverage limits (# days, type of provider, illness, treatment)

 UR
 Precertification
 medical necessity
 treatment review (multidisciplinary)
Hint: Write “multidisciplinary” no matter what the question is. It’s a big topic in Behavioral Health care.
 Case Mgmt (CM)
Use a Case Manager to ensure:
 correct diagnoses and treatments
 efficiency
 preventing relapse
 quality.

 Use A Gatekeeper (Channeling Mechanism)
A Channeling Mechanism does:
 initial assessment
 examination
 chooses a treatment plan and venue

Who should be the Gatekeeper?
 The EAP? (employee assistance program)
Adv:
 numerous
 knowledgeable
 easy and early contact

Disadv:
 not credentialled / no medical background
 may not agree with the MCO’s goals

 The PCP?
Adv:
 continuity of care
 authority is localized.

Disadv:
 PCP's may miss mental problems.

 The Case Manager?
Adv:
 full knowledge of the case
 can choose best specialist

Disadv:
 implies allowing direct access
 Utilization and cost are higher.