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By Heather Grimshaw

Health plans want provider organizations to take a holistic view of consumers with autism spectrum disorder (ASD) that includes an interdisciplinary approach, considers social determinants of health, and is reimbursed with bundled payments. This message was delivered by representatives from Cigna, New Directions, and Magellan during the “Payer Perspectives On Autism Benefits” panel at The 2019 OPEN MINDS Children’s Summit on October 28.

With one in 40 children ages three to 17 in the U.S. diagnosed with ASD (see The Prevalence of Parent-Reported Autism Spectrum Disorder Among US Children), whose care costs 4.1 to 6.2 times more than those without it, there is a shared interest in addressing the growing need for early intervention (see Another Boost in Autism Funding). Estimates that the ASD treatment market will be valued at $2.23 billion by 2022 (see Disrupting ASD Treatment: Opportunities & Challenges and The Autism Treatment Market) underscores the need for different approaches.

“You hear the term value-based payment (VBP) and what we’re looking for is outcomes,” said Katherine Wooten, LCSW, BCBA, clinical director of corporate programs for New Directions. “We’re looking for agencies that see the whole patient and recognize aspects of health including social risk factors as well as psychiatric and medical comorbidities, such as mood disorders and gastrointestinal issues. One of the best ways that providers can position themselves for future growth is to set-up a service model,”  she said and added, “Payers are hungry for that; we’re willing to pay for that” (see What Are Health Plans Doing About VBR?).

Health Plan Perspectives On VBR
Ms. Wooten joined Vik Shah, M.D., MBA, lead medical director for Cigna, and Yagnesh Vadgama, BCBA, vice president, clinical care services for autism with Magellan on the “Payer Perspectives On Autism Benefits” panel. Acknowledging the challenge of proving outcomes for ASD, which is essential for value-based payments, panelists gave suggestions for provider organizations to work with health plans to identify mutually beneficial approaches.

“Talk with your carrier early in the process of developing a bundled payment model and share the ideas you have,” said Ms. Wooten. “VBR could include a monthly or weekly bundled [payment] that lumps all services together.”

Bundled payments are increasingly used by health plans, according to OPEN MINDS reports, which show the number of health plans using some form of bundled payment or case rate rose from 39% in 2017 to 59% in 2019 (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System).

Dr. Shah noted that bundled payments tied to quality care and customer satisfaction can decrease administrative costs associated with pre-authorization, billing, collection of patient cost share, and support holistic approaches (see Billing Related Administrative Expenses in U.S. Health Care System At 8.3% Of Spending). “With a flat reimbursement you can cut through all these administrative costs and decrease your overhead expenses resulting in a 10% to 15% bump in your net reimbursement.”

He also suggested using a system’s average payment per month as a case rate or starting point to negotiate with payers.

The Need For Collaborative Approaches
All panelists acknowledged that ASD requires a unique investment of time and diverse skills, which is one reason New Directions shifted from utilization metrics to a case rate to ensure provider organizations have time to address social determinants of health that influence a consumer’s ability to follow treatment plans. “As behavioral analysts we were not taught to deal with this in school,” said Ms. Wooten.

Mr. Vadgama agreed. “There’s so much more that we need to know about the complexities of autism. We need to be using licensed clinical social workers, psychologists, board-certified behavior analysts, and other professionals to really assess what’s going on in the family structure and what comorbidities exist. Do I, as a BCBA, know all of that? Absolutely not. We need to reach out to our colleagues, take a step back, evaluate the landscape and ask what we can do differently.”

“Not all primary care practices can manage children or adults with autism,” said Dr. Shah. “It is often a challenge finding a PCP who understands young adults on the spectrum.”

Outreach to and education of PCPs could streamline care, improve outcomes, and address comorbidities that are, as Dr. Shah said, the rule rather than exception. “Introduce yourself to the pediatrician,” he said. “A phone call like this shouldn’t take more than 10 to 15 minutes. I think that’s a good practice. It’s vital to have the connection to make sure they understand your role in treatment and what’s needed for these kids.”

Learn about unique approaches to care presented during the summit later this week and check out the following resources on VBR and ASD in the OPEN MINDS Circle Library:

  1. Another Boost in Autism Funding
  2. Autism Rates & Costs: A Future View
  3. Are You In A ‘Technology First’ State?
  4. Opportunities In The Autism Market Shift With More Managed Care
  5. One in 40 United States Children Has Autism Spectrum Disorder
  6. New Opportunities Serving Adults With Autism
  7. Annual Health Care Costs For Adults With Autism 55% Higher Than General Population
  8. Prevalence Of Autism Spectrum Disorder In U.S. Stable In Recent Years
  9. Designing & Implementing Innovative Treatment Programs: An OPEN MINDS Executive Summit & Showcase
  10. Considering Cash-& Consumerism-In Service Line Planning

And join us in February 12 for the “How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating & Contracting With Health Plans” during the OPEN MINDS Performance Management Institute in Clearwater Beach, Florida.

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