the importance of payer relations
TRANSCRIPT
TheImportanceofPayerRelations:Collaboration,Evidenced-BasedTreatmentandReimbursementinyourPractice–APanelDiscussion
April7,2017DisclosureInformation
ShawnA.Ryan,MD,MBA,FASAMBoardCertifiedinEmergencyandAddictionMedicine
President&CMO,BrightViewChair,ASAMPayerRelationsCommittee
Disclosures:
ConsultantforAdaptPharma,SpeakerforOrexo
TheImportanceofPayerRelations:Collaboration,Evidenced-BasedTreatmentandReimbursementinyourPractice–APanelDiscussion
April7,2017
DisclosureInformation
FrankP.James,MD,JD,FASAM,FACLMBoardCertifiedinGeneral,ChildandAdolescent,and
ForensicPsychiatryandAddictionMedicineAssociateMedicalDirector,Optum
ViceChair,ASAMPayerRelationsCommittee
NoDisclosures
TheImportanceofPayerRelations:Collaboration,Evidenced-BasedTreatmentandReimbursementinyourPractice–APanelDiscussion
April7,2017
DisclosureInformation
AnneCarrollFernandez,MD,MBABoardCertifiedinGeneralPsychiatryandAddictionMedicine
MedicalDirectorforBehavioralHealth,CapitalDistrictPhysiciansHealthPlan(CDPHP)Member,ASAMPayerRelationsCommittee
NoDisclosures
ThespeakersonthispanelarepresentingtheirownopinionsasAddictionologistsandmembersofASAMPayerRelationsCommittee.
Theydonotrepresenttheiremployersduringthispanel.
1.DevelopBetterUnderstandingoftheImportanceofPayerRelations 2.ImproveKnowledgeofManagedBehavioralHealthCareOrganizations3.EnhanceComprehensionofPayerPerspectiveandConcerns4.DemonstrateBenefitsofCollaborationwithPayers
! 2008 MentalHealthParityActamended! 2010 PatientProtection&AffordableCareAct-Inclusion! 2017 AmericanHealthCareActv.ACA
! EmployerRetirementIncomeandSecurityActof1974(ERISA)
! FederalStatutes• HealthInsurancePortabilityandAccountabilityAct(HIPAA)• CFR42–ROIforSUDsinformationsharing• DrugAddictionTreatmentActof2000(DATA2000Waiver)
TheMentalHealthParityandAddictionEquityActof2008(MHPAEA)requiresgrouphealthplansandhealthinsuranceissuerstoensurethatfinancialrequirements(suchasco-pays,deductibles)and treatment limitations (suchasvisit limits)applicable tomental health or substance use disorder (MH/SUD) benefits are nomore restrictivethanthepredominantrequirementsorlimitationsappliedtosubstantiallyallmedical/surgical benefits. MHPAEA supplements prior provisions under the Mental HealthParityActof1996 (MHPA),which requiredparitywith respect toaggregate lifetimeandannualdollarlimitsformentalhealthbenefits.
" https://www.dol.gov/ebsa/mentalhealthparity/
! HealthBenefitCosts• Outpacegrowthinwages&isunsustainable
! Employer/CustomerConsiderations• Costsharing(e.g.highdeductibleplan)andHSAs• HighPerformanceNetworkfeaturing" Outcomes-basedpayments(NarrowNetworks)
• PharmacyBenefitManagers" Negotiatingdrugcostswhichcanmean“narrowformularies”
TripleAim:! ImprovingthePatientExperienceofCare• Includingqualityandsatisfaction
! ImprovingtheHealthofPopulations• Membercohorts;suchasC0-MorbidSUDwithHepatitisC
! ReducingthePerCapitaCostofHealthCare• Providingbenefitmanagementservicesandcreatingvalue
! Carve–Out/Vendorvs.IntegratedBehavioralandPhysicalHealth
! CaseManagementandCareCoordination
! EmphasisonResiliency,RecoveryandPrevention
! ReimbursementTrendingawayfromFee-for-Service
! FiduciaryResponsibilitytoourMembers• BestPracticeandEvidenced-BasedTreatment• MonitorandLimitFraud,WasteandAbuse
! DataAnalytics• MonitorTrendsandUtilization
! NetworkBuilding,ProviderPartners,CollaborativeStrategies• ProviderandMemberSatisfaction
! HighlyRegulatedIndustry! StateandFederalLevels
! NationalCommitteeforQualityAssurance(NCQA)! NationalMCOandHealthPlanRankings
! HealthcareEffectivenessDataandInformationSet(HEDIS)! MeasurePerformanceonVariousDimensionsofQuality
! FRAUD• Intentionalmisrepresentationofinformationforfinancialgain• (e.g.,filingclaimsforservicesthatwerenotprovidedorformorecomplicatedservicesthan
thoseprovided)
! WASTE• Extravagant,carelessorneedlessexpenditureofhealthcarebenefitsorservices
thatresultsindeficientpracticesordecisions• (e.g.,Over-utilizationofservicesormisuseofresources)
! ABUSE• Providingproductsorservicesthatareinconsistentwithacceptedpracticesareclearly
notreasonableornecessary• (e.g.,BillingforNon-CoveredServices)
! InternallyDepartmentstoMonitor,ReportandEnforce • Identifyfraudandwaste,andqualityofcareconcerns,andmakeappropriatereferralstoStateandLawEnforcementAgencies
! InternalandExternalAuditProcessesare• Relatedtofinances,performance,qualityofcare• Managementtoolsforresourceutilizationandqualityimprovement
! ProviderRecognitionandNetwork“GoldCarding”
! FraudandWasteandAbuse:ItisReal! WillFloridafinallyturnthecorneronethicsabusesin2017?
(InstitutefortheAdvancementofBehavioralHealthcare,2016)! EthicsSurvey:Blackhatmarketingbafflesthebestproviders
(InstitutefortheAdvancementofBehavioralHealthcare,2017)! SomeAddictionTreatmentPracticesareMakingMeSick
(TheHuffingtonPost,2017)
! Employer• SelectPlanOfferingso HealthMaintenanceOrganization(HMO)o ExclusiveProviderOrganization(EPO)o PreferredProviderOrganization(PPO)o PointofService(POS)o EmployerTypes
" FullyInsured(FI)" AdministrativeServicesOnly(self-fundedplan)
! PayerAccountability• PricingandUnderwriting• UtilizationandTrends• InnovationsandAffordability• Provider/MemberSatisfaction
! Provider• DifferentPlans• MultiplePayersandVendors• VariousRequirementsandManagement• PriorAuthorizations/PeerReview
! LackofAddictionologistsProviders• MedicalProvidersvBehavioralHealthProvidersvAddictionologists• DEA–X(DATA2000)/ProbuphineCertification• VariousPracticePatterns/Philosophies
! MemberandFamily• In-NetworkvsOut-of-Network• Co-pays• AlternativeLevelsofCare• CrisisPlanning• PredatoryAdvertisement/Practices• Evidenced-BasedTreatment• MultipleVendors–MedicalvBHvSUDsvPharmacy
! StateMandates• OneStandardizedMATPriorAuthorizationForm• NoMATPriorAuthorization• MandatoryMinimumBenefitCoverage–PA.MA,NY,NJ• MandatorySUDsBenefitGuidelines–TX,NYo PublicSector–ASAMGuidelines–MD,DE,WI,RI,FL,NM,TennCare,NJ(MLTSS),WA(MMI)
! StateMandates• OneStandardizedMATPriorAuthorizationForm• NoMATPriorAuthorization• MandatoryMinimumBenefitCoverage–MA,NY,NJ• MandatoryBenefitGuidelines
! IntendedResultvUnintentionalConsequences
! RespondingtotheOpioidEpidemic# SafePrescribingofOpioids# IncreasingAccesstoMedicationAssistedTreatment(MAT)# PromoteEvidence-BasedPractice/Treatment/Guidelines# ProvidingConsultationforPrimaryCarePhysicians
! AnalyticsandPredictiveModeling# High-RiskandRecidivisticMembers# StandardOutcomeMeasures# ResearchDesigns–EffectiveandCost-EfficientCare
! LeastRisktoGreaterRisk• QualityIncen4vesPrograms# Paymentsinaddi,ontofeeforserviceorperdiem
• SharedSavings# Paymentiscalculatedfromsavingsachieved
# GovernmentSharedSavingso MedicareAccountableCareOrganiza,ons(ACO)o Merit-basedIncen,vePaymentSystem/MedicaidDSRIP
• CapitatedPaymentSystem! Alterna4vePaymentModels
! ConsiderbeingonInsuranceCommittees:• P&TCommittee;• PolicyCommittee;• PhysicianCompensationCommittee
! MeetwiththeBehavioralHealthandMedicalDirector(s)• MCO/MBHOPolicies• SpecialProgramstomeetMembershipNeeds• QualityMeetingsandDataExchange