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Working With Managed Care Entities Suzanne Fields Technical Assistance Collaborative. Interest Circle Call June 3, 2010. Overview. What is a Managed Care Entity (MCE)? How is behavioral health structured in an MCE? What do MCE’s do?
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Working With Managed Care EntitiesSuzanne Fields Technical Assistance Collaborative Interest Circle Call June 3, 2010
Overview • What is a Managed Care Entity (MCE)? • How is behavioral health structured in an MCE? • What do MCE’s do? • What is the difference in roles between the MCE and the state purchaser of MCE services? • What does all this mean for Parity and HCR?
Definition of a Managed Care Entity • An organization responsible for a system of health care delivery that influences utilization , cost, quality of services, and measures performance. The goal is a system that delivers value by giving people access to quality, cost-effective health care.
Structure • Managed care takes various forms/names: • Managed Care Entity (MCE) • Managed Care Organization (MCO) • Primary Care Clinician Model (PCCM)- primary care as gatekeeper) • Pre-Paid Inpatient Health Plan (PIHP) • Health Management Organization (HMO) • Administrative Service Organization* • Integrated plan • Carve-out plan * ASO may retain responsibility for only partial list of described activities
Structure (cont) • Need to know how the MCE manages the behavioral health benefit • Is it: • Integrated within one plan • Subcontracted to another organization • Carved-out from any physical health management
Implications • Substance use disorders/addiction impacts and requires strategies that address both physical health and behavioral health • It sits at the intersection of the MCE and its’ operations • Substance use disorders predispose people to PH problems, complicate existing PH conditions, co-exist with other BH issues, and impact self-care • MCE structures that are not geared to look “across” the health of individuals, may under-recognize, under-report and under-prepare to support this population
Implications • MCE structure will inform how behavioral health –specific information is used by the MCE • Physical “side” is larger than BH “side” – inadvertent competition for resources • Depth of knowledge about substance use/addiction • How incentives are aligned (or not) to address SA • Ability to access/use data to guide action
MCE Key Responsibilities • 4 Major Activities: • Utilization Management (UM) • Quality Management (QM) • Network Management (NM) • Rates & Claims Payment • These activities are inter-dependent and are not separate activities
Utilization Management (UM) • Processes that address under and over utilization • Covered services • Criteria for access to a covered service • Medical necessity criteria • Initial, concurrent, and discharge criteria • Care Management ( and/or disease management) • Authorization--amount, duration, scope & processes used • Clinical reviews • Appeals
Network Management (NM) • Types of activities include: • Provider credentials for each covered service • Ensuring that providers can meet access standards set by federal or state requirements: • Ex: language, geography/travel time, choice • Ensuring that providers deliver services according to service definitions and clinical/practice standards (also tied to QM)
Quality Management (QM) • Types of activities include: • Evidenced-based practices (also tied to UM and covered services) • Outcome measures • Performance or service delivery process measures • Pay-for-performance
Rates & Claims Payment • Types of activities include: • Establishing rates for services • Paying “clean” claims • Pursuing any other insurance available for an MCE covered member • Fraud and abuse monitoring
Implications • MCE processes may or may not be geared to address unique aspects of substance abuse/addiction • Approaches to QM, UM or NM may pose barriers • MCE ‘s use of provider and consumer input
Differences between MCE and State Purchaser roles • Important to know when a state purchaser has authority over an issue, when it is the purview of an MCE, and when it is shared by both
Differences between MCE and State Purchaser roles* * Numerous federal requirements guide both state purchaser and MCE activities
Implications • State purchaser of MCE services may /may not be substance abuse authority for the state/level of knowledge of SA • MCE may/may not be knowledgeable about SA • Gathering information and advocating for changes may require discussions with the MCE, the state purchaser or both • Timing of changes in contract between state and MCE
Current Political Context • Wellstone-Domenici Mental Health Parity and Addictions Equity Act effective 1/1/10 • Health Care Reform • Payment reform • HIT • Private insurers and coverage • Controlling costs • Integrating care • Improving quality
Political Context (cont)Medicaid Cost Containment • Medicaid Enrollment • Services • Rates • Utilization
Implications of Parity and HCR • State purchasers and MCE’s scrambling to assess impact and implement changes • Party Act is in effect but time lag on full implementation of contracts, procedures, etc • Parity and HCR have changed how state level Medicaid programs can control their costs • No longer can use the same “levers” of enrollment, services and rates • Reliance on managed care to keep utilization in check will increase
Summary • The community expertise on SA is essential • Opportunities to partner with MCE • Opportunities to partner with state purchaser • Use of data