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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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historic trends in health care services
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.
historic trends in substance abuse treatment
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
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
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.
slide6

CD Residential Will Not Be Covered by Medicaid Products So Other Funding Sources Must Be Sought. Healthy Kids Does Have a Residential Benefit.

ambulatory detox
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.
slide10

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.

ambulatory detox1
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.