Working With Managed Care Entities Suzanne Fields Technical Assistance Collaborative

Interest Circle CallJune 3, 2010

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OverviewWhat 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?

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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.

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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

4* 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 planSubcontracted to another organizationCarved-out from any physical health

management

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Structure (cont)MCE approaches to BH

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ImplicationsSubstance 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

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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

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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

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Managed Care Activities

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Utilization Management (UM)Processes that address under and over utilization

Covered servicesCriteria 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 reviewsAppeals

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Network Management (NM)Types of activities include:

Provider credentials for each covered serviceEnsuring 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)

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Quality Management (QM)Types of activities include:

Evidenced-based practices (also tied to UM and covered services)

Outcome measuresPerformance or service delivery process

measuresPay-for-performance

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Rates & Claims PaymentTypes of activities include:

Establishing rates for servicesPaying “clean” claimsPursuing any other insurance available for an

MCE covered memberFraud and abuse monitoring

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ImplicationsMCE 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

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Differences between MCE and State Purchaser rolesImportant 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

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Differences between MCE and State Purchaser roles*

State Purchaser

MCE

Defining covered services

Use of evidenced-based practices

Defining access standards (Ex: geography, language, choice)

Ensuring standards are met by providers

Strategies used to manage utilization

Establishing provider credentialing

Establishing performance measures

Setting rates and paying claims

Use of data to improve quality and control costs

17* Numerous federal requirements guide both state purchaser and MCE activities

ImplicationsState 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 SAGathering 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

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Current Political ContextWellstone-Domenici Mental Health Parity and

Addictions Equity Act effective 1/1/10Health Care ReformPayment reformHIT Private insurers and coverage Controlling costsIntegrating careImproving quality

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Political Context (cont)Medicaid Cost Containment

Medicaid Enrollment

Services

Rates

Utilization

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Implications of Parity and HCRState 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, etcParity 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 21

SummaryThe community expertise on SA is essentialOpportunities to partner with MCE Opportunities to partner with state purchaser Use of data

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