Transcript 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.
•One strategy was to develop Partial Hospitalization Programs to stepdown the patient’s that did not require 24-hour nursing care.
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.
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.
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.
CD Residential Will Not Be
Covered by Medicaid
Products So Other Funding
Sources Must Be Sought.
Healthy Kids Does Have a
Residential Benefit.
CD PHP Is Covered but Is
Managed As an Inpatient
Benefit.
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.
InterQual® Behavioral
Health 2004
Level of Care Guidelines
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.
Antabuse®- Aversion Therapy
by Causing Sickness If Mixed
With Alcohol.
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.
ReVia®- Sigma Opiate
Receptor Antagonist
Campral®- Effects the
GABA System
Subutex (buphrenorphine)Sigma Opiate Receptor
Partial Agonist