Contracting With HMOs:

1
Contracting With HMOs
2
Historic Trends in Health Care Services

• In 1983, DRGs were developed the expectation
  was shorter inpatient stays.
• Schizophrenic inpatient stays were over three
  weeks current are less than a week.
• One strategy was to develop Partial
  Hospitalization Programs to step-down the
  patients that did not require 24-hour nursing
  care.

3
Historic Trends in Substance Abuse Treatment-

• The lunar length of treatment 28-day programs
  was modeled after common jail sentences in that
  Judges offered alcohol related convictions the
  choice of 28-days in jail or in treatment.
• Later insurance companies employer groups began
  coverage.
• In the 1980s, 28-day programs sprung up
  everywhere anyone who wanted this treatment
  could get it authorized by their insurance.
• As Government HMOs attempt to manage costs by
  shortening lengths of stay, inpatient detox
  followed by CD Partial Hospitalization Programs
  often with a board became the norm.

4
Current Trends in Health Care Services-

• As hospitals followed HMOs lead in using CD /MH
  PHP to shorten inpatient stays HMOs did not like
  authorizing PHP because it is an inpatient
  benefit.
• Often PHP or Residential are counted two for one
  against inpatient days.
• Regulations require a Physician contact once a
  week so length of stays were often on the order
  of weeks.
• HMOs patterns of authorizing less than a week at
  a time complicates the review process.

5
Compare Contrast Typical PHP Verses IOP
Programs-

• IOP is an over 90-minutes, PHP is over 4-hours
• IOP meets Monday Wednesdays Fridays.
• PHP meets weekdays or everyday.
• IOP rarely allows self-pay boarding.
• PHP often allows self-pay boarding.

6
CD Residential Will Not Be Covered by Medicaid
Products So Other Funding Sources Must Be Sought.
Healthy Kids Does Have a Residential Benefit.
7
CD PHP Is Covered but Is Managed As an Inpatient
Benefit.
8
Ambulatory Detox

• Just like inpatient detox except that the
  physician gives the patient each days
  medications and educates them on how to use it.
• The key is to trust that the patient will not
  drink or use on the detox meds.
• This can be accomplished by adequately covering
  the withdrawal symptoms.

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InterQual Behavioral Health 2004 Level of Care
Guidelines
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Medicaid Uses InterQual 1997 Level of Care
Guidelines Which Was a Section of Med/ Surg and
Looked for Medically Complicated Withdrawal
Requiring IV Fluids Etc in 2002 Behavioral
Health Split off From Med/ Surg Had Its Own
Criteria.
11
Antabuse- Aversion Therapy by Causing Sickness
If Mixed With Alcohol.
12
Ambulatory Detox

• Just like inpatient detox except that the
  physician gives the patient each days
  medications and educates them on how to use it.
• The key is to trust that the patient will not
  drink or use on the detox meds.

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ReVia- Sigma Opiate Receptor Antagonist
14
Campral- Effects the GABA System
15
Subutex (buphrenorphine)- Sigma Opiate Receptor
Partial Agonist