Our last survey of health plans found a marked increase in the reported required use of professional guidelines – 59% in this year’s survey, compared with 41% in 2017 (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System). These guidelines include level-of-care and diagnostic criteria—tools to help clinical professionals make better-informed decisions with consumer care.
Health plans expect their contracted provider organizations to use their selected care standards. OPEN MINDS Senior Associate Deborah Adler explains:
These clinical guidelines are used during the utilization review process to ensure services are being used appropriately. During a claims audit or an annual review, health plans will evaluate a provider organization’s adherence to their selected clinical guidelines and evidence-based practices. For example, several NCQA HEDIS measures are focused on specific diagnostic categories (i.e., depression, attention-deficit hyperactivity disorder, addiction disorder) and can be audited for adherence to specific guidelines through claims data. From a provider organization perspective, knowing those guidelines will decrease denials.
Looking at heath plan adoption of the guidelines, the most significant increase was in Medicare plans, increasing to 79% in 2019 from 11% in 2017. In comparison, 43% of commercial health plans used these guidelines, an increase from 4% in 2017. It’s interesting to see that Medicaid showed a slight decrease in utilization in 2019 with 44% of Medicaid health plans using the tools compared with 61% in 2017. One explanation is that state Medicaid agencies develop policies and criteria so other approved guidelines are used as secondary resources.
So, what do these tools look like?
- Cigna’s clinical guidelines for pediatric depression screening refers professionals to the U.S. Preventive Services Task Force’s recommendations published in the Annals of Internal Medicine (see Cigna HealthSpring Clinical Practice Guidelines and Screening For Depression In Children And Adolescents: U.S. Preventive Services Task Force Recommendation Statement).
- Aetna has a Level of Care Assessment Tool (LOCAT) for evaluating and determining whether a specific level of care is medically necessary for individuals with mental health disorders (see Level Of Care Assessment Tool and LOCAT, ABA & ASAM Guidelines).
- UnitedHealthcare’s clinical guidelines refers professionals to the American Psychiatric Association’s practice guidelines for treatment of addiction disorders (see UnitedHealthcare Clinical Practice Guidelines).
- Aetna’s policy for care programs and quality assurance refers health care professionals treating addiction disorders to criteria developed by the American Society of Addiction Medicine or ASAM (see An Introduction To The ASAM Criteria For Patients And Families and LOCAT, ABA & ASAM Guidelines).
Guidelines can help care teams identify strategies that improve consumer outcomes and those that don’t. Health plans expect provider organizations to evaluate their own results and show they are achieving reliable outcomes, says Ms. Adler, who added:
I do think it’s important for provider organization managers to be aware of these guidelines and use their own internal resources to evaluate their performance against those guidelines. As health plans increasingly tie payments to quality and cost, consistency in clinical practice will be more important.
See more guidelines on the Mental Health Treatment Best Practices Resource Center (see Mental Health Treatment Best Practices) on PsychU. And for more on health plan initiatives, as well as adopting evidence-based practices to prepare for value-based reimbursement, check out these resources in the OPEN MINDS Circle Library:
- Why Clinical Guidelines Matter More With Risk-Based Contracting
- What Are Health Plans Actually Doing?
- Ready For Risk? How Would Your Team Answer That Question?
- VBR @ Scale—Changes Required
- Behavioral Health Evidence-Based Practices As Population Health Management Tools
- No Whole Person Care Without Person-Centered Organizations
- Care Delivery In A Value-Based Era – Evidence-Based, Practice-Based, Standardized & Measurement-Based
- Seven Strategic Implications For Specialists In An Integrated World
- Following Best Practice – NOT
- If You’ve Seen One Audit…
Join us on February 12 at The 2020 OPEN MINDS Performance Management Institute for the executive seminar, “How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating & Contracting With Health Plans” led by OPEN MINDS Senior Associate Deborah Adler.