best practices in autism management · 2014-10-30 · applied behavior analysis (aba) utilizes...

BEACON HEALTH STRATEGIES | beaconhealthstrategies.com| October 30, 2014 | 1 Beacon Presentation for MHPA 2014 - FINAL

Presented by: Mark Heit, VP of Strategy and Development, Beacon Health Strategies Howard Savin, President of ASG, a Division of Beacon Health Strategies

Best Practices in Autism Management PREPARED FOR MHPA

October 27, 2014


Agenda 1. Beacon and Autism

2. Autism and Medicaid

3. Cost of Autism Care

4. Best Practices for Autism Management

5. Outcomes


BEACON is a national leader in managing complex populations with behavioral health conditions

COMPANY OVERVIEW

• Beacon founded in 1996 to partner with Medicaid health plans to provide integrated behavioral health benefits • NCQA and URAC accredited

• 11.5 million covered lives in 23 states, UK

• 5.1 million Medicaid members in 13 states, all LOCs

• Operating or implementing dual eligible demonstration projects in 7 states: CA, IL, VA, MA, NY, RI, MN

• Beacon acquired 100% of Autism Service Group to be clinically prepared to address increasing costs and clinical pressures from autism mandates

• Managing autism benefits in 4 states (CA, MA, NY, WA)

• Announced acquisition and merger with Value Options – due to close in Q4.

CLIENTS

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Background

• 37 states have mandated coverage of ABA services in commercial health plans, however Medicaid had always been exempt

• Some states have set caps on age, visit limits, or annual spending on services, and many states only mandate coverage for employers with more than 50 employees

• Advocacy groups, such as Autism Speaks, have played a big role in getting autism insurance mandates passed

• MH parity and challenges to state Medicaid programs created an unsustainable exemption

• In the Florida case of Garrido v. Dudek, a district court judge ruled that Medicaid must cover Applied Behavioral Analysis (ABA) to treat Medicaid-eligible minors with an ASD diagnosis, where diagnosis is identified through an EPSDT screening

Autism services prior to state plan coverage


CMS Guidance On July 7 2014, CMS issued guidance mandating that states cover medically necessary autism services for individual under the age of 21under the federal EPSDT provision

• Coverage under EPSDT: States must provide autism services under EPSDT and do not need a state plan amendment to do so

• Guidance on how to cover: Prescriptive guidance on how states can cover ASD benefits under the different 1905(a) benefit categories, the HCBS benefit, the HCBS waiver, and the demo waiver

• CMS has made it clear that a mandate of autism services coverage under EPSDT does not mean that states have to cover ABA, although it is the most common treatment modality

Considerations • Organized Advocacy. The autism community is highly organized and litigious, which creates

significant risk for access lawsuits under EPSDT

• Commercial mandates are instructive, however, the challenges under Medicaid are more severe in terms of cost, access, and administration

Recent State Action • California, Louisiana, and Washington have implemented the ABA benefit into the state plan

• The most recent state to implement ABA was California. Effective September 15, 2014, Medi-Cal MCPs must cover autism services for eligible individuals ages 0 to 21

Autism services are now a mandated EPSDT benefit under Medicaid


California published an All Plan Letter to provide Medi-Cal managed care plans (MCPs) with interim policy guidance on the provision of BHT services

Criteria

To qualify for autism services, a member must:

• Be 0 to 21 years of age with an ASD diagnosis

• Exhibit the presence of behaviors that significantly interfere with home and community based activities

• Be medically stable and without need for 24-hour medical/nursing monitoring or procedures provided in a hospital or ICF for people with intellectual disabilities

• Have a comprehensive diagnostic evaluation that indicates BHT services are medically necessary

• Services that are primarily custodial, respite, daycare, or educational are not medically necessary

• Have a prescription for BHT services from a licensed physician, surgeon or licensed psychologist

Medi-Cal Interim Policy Guidelines


Covered Services and Limitations

• Covered services must be medically necessary, prior authorized by the MCP, and be in accordance to the approved treatment plan

• Services must be administered by a qualified autism service provider or paraprofessional under the supervision of a qualified autism service provider

• BHT services must be based upon a treatment plan that is reviewed no less than every six months by a qualified autism service provider and prior authorized by the MCP for a time period not to exceed 180 days

• Treatment plans must Include care coordination and parent training

• Services must be delivered in a home or community-based settings, including clinics



Continuity of Care

• Eligible beneficiaries who are currently receiving BHT services, including ABA, through a Regional Center (RC) will continue to receive these services through a RC

• The state will develop a transition plan for Medi-Cal members currently receiving autism services through an RC to an MCP for autism services coverage

• Beneficiaries eligible for BHT services at a Regional Center after September 15, 2014 should be referred to an MCP for services

• MCPs shall ensure continuity of care for up to 12 months for members receiving services outside of the MCP network

• An MCP shall offer continuity of care with an out-of-network provider if:

• A beneficiary has seen an out-of- network provider at least twice during the 12 months prior to September 15, 2014

• The provider is willing to accept payment based on the current Medi-Cal fee schedule

• The MCP does not have any documented quality of care concerns that would cause it to exclude the provider from its network







5. Outcomes


States with the most mature mandates have demonstrated that an unmanaged system has substantial risk for high and unexplained variation in costs

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AverageBasedon Evidenceand BestPractice

ABA Hours Per Week

Age2-8

Age9-12

Age13-18

2629

33

• 20.2% of diagnosed children receiving ABA, 33% higher than benchmark

• Average Newly Authorized Hours in 2013 for new cases: 33 hours per week

• More than half of insurer reimbursed services happen in an office/daycare/school setting

• Inverse relationship between age impactability and hours authorized – blurring of education and rehabilitation

• 226 cases with annualized spending of $26 million

UTILIZATION BY AGE KEY FACTS


$0

$25

$50

$75

$100

$125

SCState Employees

$26

INCommercial

$115

MTASD Waiver

$42

Ann

ualC

osts

ofAB

A(in

Thou

sand

s)The Medicaid environment puts upward pressure on the already high costs of autism care

VARIATION IN ABA UTILIZATION MEDICAID COST CONSIDERATIONS

1. Limited point of service cost sharing will likely result in higher penetration and utilization than a commercial equivalent.

2. Low income population is less likely to pay out of pocket for services than commercially insured – commercial insurance benefits go unused when parents are committed to a current provider.

3. Medicaid will be under pressure to quickly assume financial responsibility for Medicaid children already in care through other state agencies

4. Clinical determinations will be under scrutiny by legislature due to highly active and organized advocacy groups

5. ABA services are not limited to certain diagnoses under EPSDT, therefore expected ABA utilization in Medicaid will likely be higher than in a commercial population

Nat’l Avg






5. Outcomes


The administrative requirements to effectively implement ABA for Medicaid are substantial and will impact provider participation CONSIDERATIONS

Clinical Operational


To effectively manage children with autism, a variety of services are needed to achieve optimal outcomes

• Applied Behavior Analysis (ABA) utilizes techniques for increasing useful behaviors and reducing those that may be harmful or that interfere with learning. ABA can help individuals with autism learn specific skills, such as how to communicate, develop relationships, play, care for themselves, learn in school, and succeed at work

• Occupational Therapy (OT) brings together cognitive, physical and motor skills. The aim of OT is to enable the individual to gain independence and participate more fully in life. For a child with autism, the focus may be on appropriate play, learning, and basic life skills.

• Physical Therapy (PT) is focused on any problems with movement that cause functional limitations. Children with autism frequently have challenges with motor skills such as sitting, walking, running or jumping. PT can address poor muscle tone, balance and coordination.

• Speech Therapy (ST) is intended to help individuals who are unable to speak, have difficulty understanding information, or may struggle to express themselves. ST is designed to coordinate the mechanics of speech and the meaning and social value of language

• Social Skills Group Training for Children offers an opportunity for individuals with autism to practice their social skills with each other and/or typical peers on a regular basis

• Parent Training involves parents and/or other family members and caregivers receiving training so they can support learning and skills practice throughout the day. Parental involvement is necessary to manage the overall cost of ABA services and reinforce the gains made through individual ABA therapy


VALUE AND BENEFIT

Beacon’s ABA platform provides clinical and technological tools to align resource allocation with need BEACON PROGRAM COMPONENT

Diagnostic Verification Training on use of standardized

screening tools

Comprehensive Intake & Treatment Planning

Real-Time Documentation of Progress

Limits ABA Treatment to Cases Likely to Benefit from Therapy

Ensures that authorized services are aligned with clinical best practices;

Delineates Educational from Medical Treatment; Mitigates Cost-Shifting

Clinical Documentation of Progress and Plateaus;

Ensures Supervision & Parent Involvement; Supports Practice Management

Reassessment and Reauthorization Enables Provider Behavior Shaping rather than relying on clinical denials, minimizes

lapses in authorizations


IT and operations must help support the clinical model

OPERATIONAL IMPLEMENTATION CONSIDERATIONS

• Clinical Data Management. Create process to capture and analyze outcomes in order track member progress and adjust treatment plans

• Provider Enrollment and Recruitment. Development of a streamlined process for becoming a Medicaid autism provider will be needed to address capacity needs and development of a recruitment strategy will ensure continuity of care.

• TeleHealth Standards. Accepted approaches for TeleHealth, if permitted, will need to be adopted.

• Credentialing Standards. Develop a process and criteria for credentialing providers and performing background checks for unlicensed therapists who will be providing ABA services in members’ homes.

• Care Coordination Standards and Process. Establish process and expectation for coordinating care among and between multiple agencies, schools and caregivers.

• Coordination with MCO Benefits. There must be coordination of care with MCO-covered benefits, such as speech therapy, occupational therapy and specialists to address common co-morbidities, such as gastrointestinal and dental complications.






5. Outcomes


Effective clinical management can deliver cost effective outcomes BEACON’S EXPERIENCE FROM CA MANDATE

1. Approximately 16 – 20 percent of eligible child members with ASD diagnosis will access ABA services

2. For those in active ABA treatment, average episode length is less than 18 months, with effective transition to parents and schools

3. Actual hours consumed are typically about 15 hours per week

4. In 2013, only 3 percent of cases experienced a lapse in authorized care, compared with 60 percent in 2012.

5. Audit of approximately 81 percent of all cases in care each month – more than 25 percent goal .

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Increase Target Skills

Verbal Communication

Self-Regulation

Activities in Daily Living

Safety

Social Behaviors and Interactions

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Decrease Target Behaviors

Aggression

Elopement

Self-Injury

Tantrum

CLINICAL OUTCOMES


Questions? Mark Heit VP, Strategy and Development [email protected] (978)-270-0379

Howard Savin, PhD President, Autism Services Group [email protected] (215)-327-7920

mailto:[email protected]

mailto:[email protected]

best practices in autism management · 2014-10-30 · applied behavior analysis (aba) utilizes...

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