Managed Care: Recovery Enhancer or Inhibitor?

1. Managed Care: Recovery Enhancer or Inhibitor? Sandy Forquer, Ph.D. SVP, State Government Programs OptumHealth Public Sector November 26, 2013 MHA Policy Forum Newark, New Jersey

2. It was 1995… • ValueOptions had just been awarded a behavioral health managed care contract in Colorado serving 43 counties • As Executive Director I firmly believed that recovery and self-help processes would have to be integrated into routine care delivery if our goals of cost containment and improved outcomes for persons served were to be met • Task = How to drive this philosophical change

3. Pathway to Change • While in NY state as deputy commissioner for the New York Office of Mental Health, my thinking was deeply influenced by Ed Knight, PhD, consumer leader • Ed convinced me that the integration of self-help and recovery using the tools of psychiatric rehabilitation would represent the best utilization management strategy and produce improved outcomes for persons served • Ed built a curriculum based on empowerment; as consumers began to take control of their lives, the need for self-help groups and consumer operated drop in centers increased • These activities foster the development of social networks that address the negative effects of isolation and decrease the need for high end services

4. Managed Care as Enhancer of Recovery • Major strategy =Capitation as payment mechanism • Under Colorado state rules, CMHCs in partnership arrangements with an MBHO, were permitted to reinvest savings in improvements in the system • Savings from capitation served as major source of funding for the psychiatric rehabilitation training, formation of drop-in centers and resources needed to move to a recovery-oriented system of care • “We couldn't have made these changes in how we deliver care without managed care. Before managed care, all our strategies focused on maintaining our financial base.”

5. Managed Care as Inhibitor of Recovery • Four early inhibitors included: • Staff resistance toward not only managed care but also recovery • Managed care companies back in the 90’s were not familiar with the research on the value of mutual support and psychiatric rehabilitation • Persons with mental illness were viewed as requiring maintenance, not growth strategies • Continued use of fee-for-service within the managed care environment, providing managers and boards with no incentive to change • Suspicion from consumers about self-help; viewed as a means to cut services and not give them what they needed

6. Lessons Learned • Provision of self-help services can have an impact beyond what might be anticipated • Resistance of professionals can be successfully addressed if concepts and skills are pit in place to fill the vacuum created when we realize that our interventions are not producing the desired outcomes • Resistance is not a one time phenomenon; the ability of a trainer to deviate from a planned module and facilitate a discussion about the resistance is invaluable in moving forward • The opportunities that self-help create for individuals to build social networks through access to leisure activities should not be underestimated • Powerful complementary activity to therapeutic activity • Adapted from Forquer, S. and Knight, E. Managed Care: Recovery Enhancer or Inhibitor? Psychiatric Services 2001; doi: 10.1176/appi.ps.52.1.25

7. Advances in Supporting Recovery by Managed Care Companies: Moving Forward to 2013 • Peer Support Services are an expanding part of the continuum of care provided for behavioral conditions • Peer providers are increasingly part of the provider network of a managed care company • Peer Support Services (PSS) have been deemed an evidence-based reimbursable model of care by the Centers for Medicare and Medicaid Services • States, counties, employers and health plans are increasingly covering PSS in benefit plans • BUT: Lack of Level of Care or medical necessity criteria for PSS exists • This is an issue because these criteria serve as standards for determining coverage and reimbursement

8. 2007: Medicaid Deems PSS an Evidence-based Practice • PSS are reimbursable in states that build these services into their state plan • Medicaid, state-funded behavioral health care and health home pilots increasingly requiring PSS as part of their contracts (Daniels AS, Tunner TP, Bergeson S, et al: Establishing Standards for Excellence. www.pillarsofpeersupport.org/POPS2012.pdf) • Need identified to establish Level-of-care guidelines for PSS to be consistent with other clinical services

9. One Managed Care Companies” Approach to LOC Guidelines for Peer Services • Level of Care Guidelines provide objective and evidence-based admission and continuing stay criteria for mental health and substance use services offered by the providernetwork in support of the member’srecovery/resiliency. They are intended to standardize care advocacy decisions regarding the most appropriate and available level of care needed to support a member’s path to recovery. • The evidence-base for the Level of Care Guidelines includes generally accepted standards of clinical practice, as well as governmental standards such as CMS’ National Coverage Determinations (NCDs) and Local Coverage Determinations • From Optum’s Level Of Care Guidelines, 2013, available at www.optum.com

10. Level of Care Guidelines for Four PSS Now Exist • Recently published LOC Guidelines for PSS can be found in: • Daniels AS, Cate R, Bergeson S, Forquer, S et al, Level-of-Care Criteria for Peer Support Services: A Best Practice Guide, Psychiatric Services in Advance, October 15, 20`3; doi:10.1176/appi.ps.201300277 • Some highlights from these Criteria include: • Development of four level-of-care criteria sets for : • Peer-to-peer services and supports • Peer bridger services • Family-to-family support services • Family peer bridger and navigator services

11. Level of Care Guidelines for Four PSS Now Exist • Each include: • Review of applicability of these services • Description of the services • Review of scientific and other evidence • A review of governmental services • Indications for coverage • Applicable service codes • References • Excerpts from LOC guidelines for peer bridger services • Description: Peer bridger services is a form of community support service in which a certified peer specialist assists an adult member who is recovering from a severe and persistent mental illness with engaging in treatmentr and other community supports…

12. Level of Care Guidelines for Four PSS Now Exist • Indications for coverage • Member must have a severe and persistent behavioral health condition • Member must also meet one of the following criteria: • Member has significant difficulty consistently and independently accessing or utilizing ambulatory behavioral health or medical care • Member has significant difficulty consistently and independently managing age-appropriate activities of daily living including finances, hygiene, nutrition and meal preparation, home maintenance, child care, or legal housing, transportation, and other community service needs • Member has significant difficulty maintaining employment or meeting educational goals • Member lives in unsafe environment or impermanent housing

13. Level of Care Guidelines for Four PSS Now Exist • Member does not have family or social supports or the family or social supports cannot help member utilize care or manage his or her behavioral health condition • Both of the following criteria must also be met: • Member is not at imminent risk of serious harm to self or others • Member has a treatment plan that adequately addresses his or her behavioral health and co-occurring general medical conditions

14. Summary • Managed behavioral care organizations recognize the evidence supporting the use of peer support services in achieving the Triple Aim: • Improving outcomes of persons served • Improving the satisfaction of person served with services received • Bending the cost curve

15. Thank you. For more information, please contact: sandra.forquer@optum.com