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Contracting With HMOs:

Contracting With HMOs: . 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.

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Contracting With HMOs:

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  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 patient’s 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 & HMO’s 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 HMO’s lead in using CD /MH PHP to shorten inpatient stays HMO’s 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 day’s 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.

  9. InterQual® Behavioral Health 2004Level of Care Guidelines

  10. 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 It’s 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 day’s 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.

  13. ReVia®- Sigma Opiate Receptor Antagonist

  14. Campral®- Effects the GABA System

  15. Subutex (buphrenorphine)- Sigma Opiate Receptor Partial Agonist

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