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
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
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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
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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.”
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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
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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
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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
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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
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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 provider network in support of the member’s
recovery/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
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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
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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…
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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
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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
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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
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Thank you.
For more information, please contact:
sandra.forquer@optum.com