Presentation on theme: "Contracting With HMOs:. Historic Trends in Health Care Services In 1983, DRGs were developed & the expectation was shorter inpatient stays. Schizophrenic."— Presentation transcript:
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. 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- 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- 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- 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.
CD Residential Will Not Be Covered by Medicaid Products So Other Funding Sources Must Be Sought. Healthy Kids Does Have a Residential Benefit.
CD PHP Is Covered but Is Managed As an Inpatient Benefit.
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.
InterQual® Behavioral Health 2004 Level of Care Guidelines
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.
Antabuse®- Aversion Therapy by Causing Sickness If Mixed With Alcohol.
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.