Managed Care and Health Insurance HSM 420- Course Project June 24, 2016 Professor Managing Quality Improvement in Managed Care Table of Contents Introduction..............................................................................................................................................3 Managed Care..........................................................................................................................................3 Background.............................................................................................................................................4 Types of Managed Care...........................................................................................................................4 Managing Behavioral Health...................................................................................................................5 Cost Impact of Managed Care on Behavioral Health...............................................................................6 Assuring Access to Managed Care..........................................................................................................7 Improving Quality in Managed Care.......................................................................................................7 Quality Drivers in Managed Care............................................................................................................8 Challenges Associated with Quality Improvements in Behavior Health................................................10 Recommended Solutions for Quality Improvements in Behavior Health..............................................10 Summary and Conclusion......................................................................................................................11 Work Sited............................................................................................................................................12 Managing Quality Improvement in Managed Care 2 Managing Quality Improvement in Managed Care Introduction When we speak of managing quality improvements in managed care healthcare we have to consider a broad spectrum of indicators such as; the impact of managed care on mental health, and substance abuse, the cost associated with managing behavior health, improving quality and assuring access for mental health and substance abuse care. We will attempt to acquaint you to with some or most of these indicators throughout the course of this paper. Understanding the transition of organizations from conventional insurance standards to a managed care delivery system and its ability to evolve in diverse ways in the future. This paper will provide some background on managed care evolution and it's prospective for quality in the future. It will also describe the policies and regulations associated with various types of managed care programs; and in conclusion will identify challenges and recommendations on improving quality care within managed care organizations. Managed Care Most of us are quiet familiar with the earlier traditional types of insurance coverages such as indemnity policies and/or fee-for-service type policies. Managed care has created some drastic changes in the way we are serviced in the health care industry today. In response to these changes new approaches to healthcare has fasttracked the progression of managed care. This growth in managed care also stemmed the enactment on organization to institute controls in managing and improving quality measures; and in providing accountability of the delivery of healthcare and to realize consumer's goals in attaining access to care, quality of care, effectiveness of care, and cost of care. Managed care approaches has changed the path of health care organization in general by influencing the delivery of privately and publicly reimbursed behavioral health treatments. The transition of managed care for the treatment of mental health and substance abuse (alcohol and drug) problems, also known as behavioral health for the ; most part was also expedited but not without its challenges since these behavior health care treatments were being 3 Managing Quality Improvement in Managed Care administered in primary care setting creating potential problems in quality and access to behavioral health care under managed care system . The managed care movement also brought about new regulatory processes and reforms. New quality monitoring mechanisms was created; accreditation processes; quality improvement and performance measurements; licensing, and other credentialing activities; consumer protections; confidentiality; also, Medicaid and Medicare reforms. Background In 1995 managed care experience its peak with inordinate haste and it came in many forms and not without controversy. With the creation of Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service plans (POSs) almost sixty percent of the total population belonged to some form of managed health care plan. Although it may have reached its peak in 1995, the introduction of HMOs date as far back as the 1930's where the first prepaid practices group was established. Then during the mid-1980s, managed care went through some important stages focusing on managing . access to health care, managing benefits, and on managing care Currently, the latest stage in the evolution of managed care and the greatest focus most linked with managed care is cost containment. These plans in contrast to traditional plans enabled practitioners to manage care in a way to improve and coordinate care, as well as to increase emphasis on prevention of care (Edmund) In comparison with indemnity plans, managed care plans has increasingly lower the cost of inpatient care, costly and discretionary examinations, and has augmented the use of preventive services. Both private-sector employers, and public-sector employees; government agencies and public-sector agencies; also, other consumers of health care became progressively antagonistic in their quest for competitive pricing from providers of health care services. Types of Managed Care 4 Managing Quality Improvement in Managed Care What all managed care organizations have in common is that they all generally institute a contractual agreement with physicians, hospitals, clinics, and other health care providers such as pharmacies, diagnostic services, and medical equipment vendors to make-up a manage care network. There are three types of managed care plan; which are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Point of Service (POSs) plans. There are some distinctions in the various plans but with one noted similarity and that is they are all designed to be cost effective in providing health maintenance services to guard against serious health problems. Managed care organizations are the principal players in the health insurance game with \"HMOs being the biggest kinds of managed care insurance providers in the country\". HMOs rely on capitation and other incentives to control costs. They deal in large groups of people, which lower the fees, charged by the doctors and medical facilities that contract with organization. The group practice structure of a HMOs permits enhanced synchronization between primary care and specialty physicians, for instance, physicians are co-located and medical records are more easily shared . PPOs allow more flexibility with access to any physician or medical facility within their network. But they also cost more. PPOs are a network of physicians organized by insurers, a managed care organizations, or groups of physicians that charges by means of a fee schedule. POS plan is sort of a mixture between the two (HMOs and PPOs); they also allow more flexibility with access to any physician or medical facility within their network. But with a POS you are allowed to go outside the network if your primary physician authorizes it. POS also uses a network of designated physicians that's compensated either by means of capitation or fee-for-service. A primary care physician is the gate-keeper to specialists, and copayments for seeing practitioners within the plan. Managing Behavioral Health Within a managed care environment managing behavior healthcare is somewhat obstinate. It becomes challenging to improve the coordination of care between medical and behavioral health providers. As previously stated all managed care organizations are distinctive with a basic similarity and that is they are all designed to be 5 Managing Quality Improvement in Managed Care cost effective in providing health maintenance services to guard against serious health problems. With behavioral health care it does not appear that the similarity under which they all function cannot be so easily adapted as the keys words are cost saving and preventive care an oxymoron in behavior health. So the question becomes \"How can behavioral health clinicians provide managed care in an ethical, professionally satisfying manner while as well dealing with managed care organizations (MCOs)\"? This question has spawn different strategies focusing on the management of hospital episodes of care under managed care. Let's focus on managed care as it relates to mental health services. In comparing the use of mental health services in a managed mental health care program designed to reduce inappropriate use of hospital services with the purpose of containing costs. Cost Impact of Managed Care on Behavioral Health The cost of mental healthcare has exploded in comparison to other segments of within the healthcare industry. In an attempt to contain the mounting cost of behavioral healthcare utilization management is identified as the number one singular managed care instrument, which has grown in recognition in an absolute ratio to the increase in the cost of mental health care. To curtail the surge of growing cost the healthcare industry gyrated to utilization management in an attempt to shrink hospital use and, indirectly, reduce spending for psychiatric and substance abuse care; even though it was viewed as an undesirable imposition into clinical affairs. Utilization management is taunted as a major strategy in reducing hospital use and spending for psychiatric and substance abuse care. It came with a promise to contain cost in the area of behavioral health by concentrating on discharge planning rather than admission and assigned length of stays. Since it had been determined that behavior health admissions typically were categorized as emergent admissions instead of planned admissions it was more feasible to focus on the treatment as it relates to discharge, thus shortening the length of stay by encouraging efficiency on the part of the clinical treatment team rather than preventing or shortening treatment objectives capriciously. There has been studies (Dickey & Azeni) conducted to test the effect of managed care programs on measures of utilization and on expenditures with only subjective information at best. These studies shows that the 6 Managing Quality Improvement in Managed Care program reduced hospital use by eight percent; for mental health, and suggested that the rate of rising costs has been slowed. Assuring Access to Managed Care The trend in the direction of integrated medical and behavioral health has intensified with the Patient Protection and Affordable Care Act (ACA) which included mental health and substance abuse as part of essential health benefits; and the implementation of the Mental Health Parity and Addiction Equity ACT (MHPAEA) placed greater emphasis on the provision of substance use services within Medicaid. While traditional Medicaid was not required to comply with the parity provisions, managed care plans serving Medicaid expansion must comply. But in order for a managed care program to be successful then fewer individuals would have to be admitted into an inpatient environment; on the other hand for those that are admitted their expected stay should be determined by the severity of their illness and not cost or length of their stay; and hopefully there would also be an increase in outpatient services to substitute for reduced hospital care. True integration of clinical services into a managed care program requires access to appropriate personnel, services and supports that are paid for and aligned within the managed care approach. Moreover, this approach must also address a broad rang of services and provider capabilities. In addition, different managed care programs have many different impacts on patients with serious mental illnesses, emotional disturbances, substance abuse disorders and other disabilities. In accordance with the National Council of Behavior Health report written and documented by Wendy Holt and Richard Dougherty, the managed care program must meet the needs of the population, provide resources for advocated to educate policy makers and ensure that this vulnerable population's special needs are addressed throughout the transition to managed care. To ensure access the integrated managed care program must include physical health and behavioral health benefits in the same health plan. Assertive outreach must be provided in order to support individuals in their homes and other community locations. Treatment organizations must build a relationship with these individuals to engage them in services. Improving Quality in Managed Care 7 Managing Quality Improvement in Managed Care Some view managed care organization simply as a cost saving initiative; while MCO's are pugnaciously attempting to demonstrate to the healthcare community that managing quality is just as important as managing cost. A myriad of entities have questioned the goal of MCOs they fear that managing care means to manage costs. Just as importantly most feel that MCOs that are for-profit managed care organizations legal and fiduciary responsibility are first to their stockholders and secondary to their clients or customers. Additionally, current inclinations has shifted the financial risk to providers through capitation or other structures that compensate providers for efficiency concurrently giving providers a financial incentive to withhold necessary care. This is just a narrow list of explanations as to why MCOs are being barraged with a series of assaults regarding the quality of care that they deliver. With these quality view issues as a framework, regulators, accreditors, businesses and customers equally are placing increasing demands on MCOs to clearly and openly address quality. Quality Drivers in Managed Care Bearing in mind that there are numerous factors driving MCOs to pay specific consideration to the quality of care and service they deliver. Most noteworthy is that singularly any one of these drivers can have an impact on the quality of care provided by an MCO, but collectively their impact has proven to be monumental. MCOs has revolutionized the traditional quality assurance mechanism previously employed; by implementing a comprehensive understanding of quality improvement and quality management undertakings in order to build upon and enhance their performance. Carefoote in her published article on Managed Care and Quality Management has provided us with a list of these undertakings that are driving the quality progression in managed care. These are just a sampling of drivers affecting changes in managed care. State Oversight - in order to ensure access and quality of care in MCOs are in essence requesting HMOs to provide specific QA plans corrective action plans readily available when problems are noted. Federal oversight - which has the responsibility for overseeing specific MCOs including federally qualified HMOs and those plans enrolling Medicaid and Medicare enrollees has outlined in the 8 Managing Quality Improvement in Managed Care federal statute a comprehensive set of benefits that HMOs must provide along with specific requirements for the HMO reports on utilization patterns, availability and accessibility. Voluntary Accreditation - Since most MCOs are not mandated to obtain formal accreditation, the competition from other accredited organizations is compelling them to do so. In the area of voluntary accreditation, there are three primary drivers -- The National Committee on Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Utilization Review Accreditation Commission (URAC). Standardized Performance Indicators - The Health Employer Data and Information Set (HEDIS) contains more than 60 performance measures and is a renowned indicator of quality in managed care today. Responsibility for HEDIS currently resides with NCQA. HEDIS was designed to provide MCOs with a standardized reporting format for identifying quality improvement indicators. It also enables MCOs to track their performance over time. Employer and Business Mandates- Historically, employers have evaluated health plans based on costs alone, but that's changing. Current conditions have caused employers to move away from evaluations based on costs alone to evaluations that include financial efficiency and quality components. Now employers want to ensure that they are receiving value for their health care dollar, simply because a plan that costs less may result in higher claim costs due to poorer quality. They also want the development of standard performance indicators such as those found in HEDIS, which enables employers to compare health plans in meaningful ways; employees are now better educated about quality health care and are asking their employers about the quality provided by health plans before they make a choice; finally, some employer groups are hiring benefits managers with clinical backgrounds, recognizing that there is a relationship between effective clinical management and low claims costs. It seem that cost as well as quality of care has become a major focal point in the competitive arena of MCOs no longer is the customer directed to a manage care plan like in the past when they had very few indicator to determine what was best for them. They are now equipped with knowledge; and indicators of what is and what isn't quality healthcare; and MCOs are finding themselves competing for your business. 9 Managing Quality Improvement in Managed Care Challenges Associated with Quality Improvements in Behavior Health The most obvious and the most threatening challenge associated with quality improvement in behavioral health exist in the absence of a publicly managed care system that serves as a failsafe for mental health and substance abuse patients. True enough public services are obtainable for those with public insurance, also for those who have private insurance. But public services are subsidized by a number of unqualified programs administered by diverse agencies, creating both redundancy and gaps in service, and with varying eligibility requirements that in addition is predicated on fragment funding, which leads to fragmented service delivery. The most difficult challenge to quality care in behavioral healthcare is the episodic care being administered in primary care settings where primary care practitioners tend to misdiagnose depression, substance abuse, and other behavioral health problems that requires better coordination of care. As with any methodology designed in pursuit of transforming behavioral health services or to address the problem of accountability must take into account the aforementioned challenges, which are not concurrently ongoing in any other segment of health care services. The dynamics of publicly managed care system, the private managed care system and specialty health are so interconnected and multifaceted; with different characteristic from one state to another, from communal to communal, and from plan to plan. Recommended Solutions for Quality Improvements in Behavior Health A number of tactics should be employed in the development of new tools needed in addressing the quality of care: primarily the development of prototypes necessary for the coordination of mental health and primary care professionals in identifying best practices in the coordination of all care for primary and behavioral health care. The continual need for improvements in the areas of; accreditation, licensing and certification, credentialing and privileging, and the use of practice guidelines, performance measures, report cards, and other means are other tactics needed in continual improvement. Yet, bears a resemblance to the multifaceted collaged that currently exist, replicating the fragmented structure in the delivery of the care and the comprehensive range of data and sentiments about quality of care. 10 Managing Quality Improvement in Managed Care Summary and Conclusion The social significances of behavior healthcare are problematic and considerable more distressing than generally surmised. The prevalence of behavioral health in society is rather enormous, and the economic encumbrances are substantial. Throughout this paper we have discussed some of the foremost trends that have and continue to affect health care delivery. With the enactment of PPACA we have seen an increase in the numbers of individuals enrolled in managed care plans; including a large number of individuals with chronic and severe health problems. We have hope in the continual trend in the shift from public view of managed care as an edifice more concerned with quality of care rather than an edifice concerned with cost containment. Deficiency in either of this area can only result in a negative effect on health care delivery rather than a positive outcome for all. 11 Managing Quality Improvement in Managed Care WORKS CITED: Basic Types of Managed Care - HMO, PPO, POS (n.d.), Retrieved: http://www.goinsurancerates.com/healthinsurance/basic-types-of-managed-care/ Blair, Michael. Understanding Managed Care Plans (May, 2016). Retrieved: https://www.verywell.com/understanding-managed-care-1739066 Carefoote, Robert. Managed Care and Quality Management; Signature Series (1998). Retrieved: http://www.mcres.com/mcrmm03.htm Dickey, B, Azeni, H. (1992) Impact on Managed Care on Mental Health Services; Health Affairs 11, no 3 Retrieved: http://content.healthaffairs.org/content/11/3/197.full.pdf Edmunds, Margaret, (1997) Managing Managed Care: Quality Improvements in Behavioral Health: Institute of Medicine (US) Donaldson, M, Yordy, K, Lohr, K, Vanselow, (1996) Primary Care, America's Health in a New Era. Institute of Medicine (Washington, DC) Retrieved: http://www.nap.edu/read/5152/chapter/1 Holt, W, Dougherty, R. (2014) Ensuring Access to Behavioral healthcare through Integrated Managed Care: Options and Requirements National Council for Behavioral Health Retrieved: http://www.thenationalcouncil.org/wp-content/uploads/2014/11/14_Managed-Care-2.pdf The Problems with Managed Care (n.d.), AFSCME Public Policy Department (August 1998) Retrieved: http://www.afscme.org/news/publications/health-care/managed-care-comes-to-mentalhealth/the-problems-with-managed-care 12