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