Sec P MH, PCMHs, Pmt Reform

Question 1

Types of services delivered by commercial behavioral health care networks

Answer 1

1. Inpatient services - the highest level of skilled services. Involves 24-hr medical and nursing care in a psychiatric facility, a general hospital, or a detoxification unit in a hospital
2. Residential treatment - services rendered in a 24-hr facility offering therapeutic services for patients with severe mental or substance-related disorders
3. Partial hospitalization - provides structured mental health or substance abuse therapeutic services for at least 4 hrs per day and 3 days per week
4. Intensive outpatient program - provides structured therapeutic services for at least 2 hrs per day and at least 3 days per week
5. Outpatient treatment - includes individual, family, or group treatment rendered by a licensed professional
6. Employment assistance programs (EAPs) - EAP professionals deliver short-term, problem-focused outpatient services for employees and their families

Question 2

Types of mental health providers

Answer 2

1. Psychiatrist - a physician who specializes in mental health and is able to prescribe drugs
2. Psychologist - has a doctoral degree in psychology and two years of supervised professional experience
3. Clinical social worker - a counselor with a master’s degree in social work
4. Licensed professional counselor - has a master’s degree in psychology, counseling, or a related field
5. Certified alcohol and drug abuse counselor - has specific clinical training in alcohol and drug abuse and provides individual and group counseling
6. Psychiatric nurse practioner or nurse pyschotherapist - a registered nurse practioner with special training in psychiatric and mental health nursing
7. Marital and family therapist - a counselor with a master’s degree and special training in marital and family therapy

Question 3

Utilization management strategies to reduce inpatient behavioral health care costs

Answer 3

1. Addressing psychosocial causes of admissions in order to get early treatment and avert the need for admission
2. Increasing ambulatory follow up to help prevent unnecessary readmissions
3. Reducing readmissions through intensive interventions for at-risk patients
4. Measuring and tracking clinical performance with a focus on outcomes and efficiency
5. Reducing relapse through effective aftercare planning and use of community and social supports
6. Coordinating services among multiple agencies and providers
7. Emphasizing the quality of services provided through supervision, analysis of complaints, satisfaction surveys, and staff training

Question 4

Data sources for behavioral health care performance metrics

Answer 4

1. Administrative data - includes claims, eligibility information, and various coding sets
2. Treatment records - contain detailed clinical information
3. Survey data - from providers and consumers
4. Access data - from reviews of provider appointment availability
5. Clinical assessments - involve consumer self-report and provider and caretaker observations
6. Utilization management data - include requests for care, nonauthorizations, and appeals
7. Risk management data - include adverse events and medication errors
8. Predictive modeling data - derived from utilization data and population risk adjustment formulas

Question 5

Types of behavioral health care services delivered by public section networks

Answer 5

1. Supervised living - includes community-based residential detox programs and rehab in halfway and quarter-way houses
2. Programs for assertive community treatment - multidisciplinary teams deliver services directly in the community to people who demonstrate chronic symptoms and a pattern of relapsing
3. Peer support - consumers who have recovered work under the supervision of a behavioral health provider that assists patients in building confidence and in improving life skills
4. Continuous treatment teams - multidisciplinary teams provide a range of services in an effort to prevent a child from needing to be removed from the home and placed in a more restrictive level of care
5. Community case management - workers coordinate care and social services delivered within the community

Question 6

Key success factors of a patient-centered medical home

Answer 6

1. Improved quality of care
2. Improved status of comorbid conditions
3. Increased satisfaction of patients
4. Reduction of avoidable comorbid hospitalizations
5. Reduction of acute occurrences
6. Reduction of inpatient admissions
7. Reduction of LTC admissions

Question 7

Principles for establishing a patient-centered medical home

Answer 7

1. Personal physician - each patient has a personal physician trained to provide comprehensive care
2. Physician-directed medical practice - consists of a team of individuals taking responsibility for the patient’s ongoing care
3. Whole person orientation - appropriately arranging care with other qualified professionals
4. Care coordinated and integrated across all elements of the health care syste, and the patient’s community
5. Quality and safety - includes patient-centered outcomes, evidence-based medicine, and continuous quality improvement
6. Enhanced access through open scheduling, expanded hours, and E-visits
7. Reimbursement structure to support and encourage this model of care

Question 8

Functions (or components) of patient-centered medical homes

Answer 8

1. Comprehensive care - provided through several different care providers
2. Patient-centered - a relationship-based process to educate patients and allow them to define the levels of care with which they are comfortable
3. Coordinated care - incorporating the entire health care system in order to facilitate communication about the patient and discuss best practices among different provider groups
4. Accessible services - providing multiple channels for the patient to be able to reach out and gather information or receive care
5. Quality and safety - implementing quality improvement measures while taking into account the patient’s progress, concerns, and overall well-being

Question 9

Benefits of being designated an FQHC

Answer 9

1. Reimbursement for services provided under Medicare and Medicaid
2. Medical malpractice coverage
3. Eligibility to purchase medications for outpatients at reduced cost
4. Access to National Health Service Corps
5. Access to the Vaccine for Children Program
6. Eligibility for various other federal grants and programs

Question 10

Types of clinics that can be used to provide basic health care

Answer 10

1. Retail convenient care clinics - many pharmacies, hospitals, and grocery chains have opened retail clinics staffed by nurse practioners. These clinics offer care on a walk-in basis for common, non-urgent illnesses, and are generally open during evenings and on weekends
2. Employer worksite clinics - these are most common at very large employers. They may cover various types of care, such as preventative services, acute care, primary care, pharmacy, disease management, and wellness
3. Urgent care clinics - freestanding centers that are staffed by a full range of clinicians, who are directed by physicians. They are generally open longer than physician practices, and they offer a full range of ambulatory services, including many that are offered at hospital emergency departments
4. Federally qualified health centers (FQHCs) - these are designated by the federal government to provide health care to the underserved and uninsured. An e.g. is a community health center

Question 11

Types of physicians and other professional providers

Answer 11

1. Primary care physicians (PCPs) and specialty care physicians (SCPs) - for traditional HMOs, the distinction between PCP and SCP is very important because the PCP acts as a gatekeeper and must authorize any visits to a specialist
2. Hospital-based physicians - specialties include radiology, anesthesiology, pathology, emergency medicine, and hospitalist. These physicians often have exclusive rights at a hospital, so they are reluctant to contract for anything less than full charges
3. Nonphysician or mid-level practitioners that provide primary care - the most common are physician assistants and nurse practioners. These are a great asset in managed care because they deliver excellent primary care, tend to spend more time with patients, and are well accepted by most members
4. Mental health providers
5. Other types of professionals - podiatrists, dentists, orthodontists, optometrists, chiropractors, physical therapists, nutritionists, acupuncturists, audiologists, respiratory therapists, and home health care providers

Question 12

Challenges related to delivering telehealth care

Answer 12

1. Technology infrastructure - the technologies available are constantly expanding
2. Cost - the capital investment required for telehealth infrastructure can be prohibitive for some organizations and communities
3. State licensing and regulation - professionals who use telemedicine technology across state lines must apply for a separate license in each state
4. Payment - a # of payers have recently started covering telehealth and “web visits” for their members

Question 13

Delivery mechanisms for telemental health services

Answer 13

1. Hub-and-spke networks - these link large tertiary centers with outlying clinics
2. Health provider-home connections - these link providers with single-line phone-viedoe systems for interactive consults
3. Web-based e-health patient service sites - these provide direct consumer outreach and services over the internet

Question 14

Qualities an organization needs to succeed under payment reform

Answer 14

1. Highly integrated system
2. Effective care management initiatives
3. More efficient health system than the rest of the market
4. Select and restricted networks
5. Collaborative relationship between the provider organization and payers to reduce costs
6. Reasonable methods to establish capitation rates, episode payments, and other payments
7. Equitable methodology for allocating global capitation payments or quality incentives among the individual participating providers

Question 15

Practical issues that have determined the success or failure of previous value-based arrangements

Answer 15

1. Engaging all stakeholders (e.g., policymakers, actuaries, and providers) is important
2. Payment reform is organization-specific - there is not one payment structure that is the best in all circumstances
3. Results of payment reform and decidedly mixed, with both successes and failures
4. Success in provider payment arrangements depends on good holistic risk management by the payment reform team
5. Organizations need various qualities to succeed under payment reform
6. Insurance companies have an important role in payment reform since they can pool and reduce insurance risk. Providers must be required to take on some insurance risk, which they must carefully monitor
7. The mechanics and administration of payment models that incorporate provider risk have improved since the 1990s consumer backlash against them

Question 16

The actuary’s role in payment reform

Answer 16

1. Lead the pricing exercise
2. Help quantify the risk - help the provider understand the various risks the provider is taking when selecting a payment model
3. Calculate the correct price for the selected payment model
4. Help project and model cash flows

Question 17

Definitions related to payment reform

Answer 17

1. Value-based arrangement - an arrangement where a payer and a patient seek quality and efficiency. The opposite of a volume-based arrangement
2. Payment reform - the environment where more contracts move to value-based arrangements
3. Payment model - the manner in which a payer reimburses providers
4. Service delivery model - the manner in which providers organize and deliver care to patients. Can refer to an approach (such as telemedicine) or organization (such as an accountable care organization (ACO))

Question 18

Types of ancillary services

Answer 18

1. Diagnostic
   a) Laboratory
   b) Imaging (x-rays, MRIs)
   c) Electrocardiography
   d) Cardiac testing
2. Therapeutic
   a) Cardiac rehabilitation
   b) Noncardiac rehabilitation
   c) Physical therapy
   d) Occupational therapy
   e) Speech therapy
   f) Other long-term therapeutic services
3. Pharmacy
4. Ambulance and medical transportation services

Question 19

Types of health care facilities

Answer 19

1. Community-based single acute care hospitals
2. Multihospital systems (MHSs) - consolidation has led to most hospitals being part of an MHS, which gives them negotiating leverage
3. For-profit national hospital companies - because these hospitals are owned by national companies, they have much less local autonomy
4. Specialized hospitals - these provide care to only a certain type of patient (e.g., children’s hospital and psychiatric hospitals)
5. Physician-owned single-specialty hospitals - these restrict themselves to elective procedures within a single specialty, so they are not equipped to handle emergencies and severe conditions
6. Accountable care organizations (ACOs) - these coordinate care for designated Medicare FFS beneficiaries and participate in a shared savings program
7. Government hospitals - may be county-run, state-run, or federal
8. Subacute care (skilled or intermediate nursing facilities) - these are well suited for prolonged convalescence or recovery cases. The cost for a bed day is much less than in an acute-care hospital
9. Ambulatory surgical centers (ASCs) and procedure centers - are typically equipped to handle only routine cases
10. Hospice - a broad term referring to health care services provided at the end of life, which may be at an inpatient facility, ambulatory facility, or no facility
11. Retail health clinics - small clinics usually associated with a retail store (such as Target or Walgreens). Provide basic primary care services, such as immunizations and preventive screenings
12. Urgent care centers - a hybrid of a low-level emergency department and a PCP practice
13. Other types of ambulatory facilities - includes centers for birthing, community health, diagnostic imaging, occupational health, pain management, and women’s health

Question 20

Roles of the payment reform team

Answer 20

1) Actuary - quantify risks and prepare financial models
2) CFO - set a budget and allocate resources to keep the health system within the budget
3) Clinicians - provide high-quality care in order to achieve customer satisfactino and good outcomes
4) Coding specialists, data analysts, and information technology specialists - make sure other team members are receiving timely and accurate information
5) Policymakers - address systematic issues such as shortages of PCPs