A Note on the State of Managed Care

Rich_Appert_DSC04193_cl_112315A Word from Our Director of Admissions:
Rich Appert

A recent admission to Sierra Tucson had me reflecting on our industry’s current interaction with commercial payers and managed care as a whole. While legislators and advocacy groups continue to trudge forward from a bureaucratic perspective (moderately successfully), it’s hard not to grow mildly disconcerted at the “one step forward, two steps back” nature of the relationship. The downward trend in residential lengths of stay is not really improving despite the apparent progress of both the Mental Health Parity Act (MHPA) and the Affordable Care Act (ACA). While discussing the aforementioned case both internally and with the referral source, the realization that the onus is on us (providers, employer groups, referral sources) to affect positive change has become exceedingly evident. The pushback has to become more severe. The alternative is that the residents we care so much about won’t get the help they so desperately need.

I should mention that we are doing remarkably well at Sierra Tucson when it comes to average length of stay at the residential level of care. Through the first two quarters of the year, we have been right around 27-28 days, which is even better than it seems when one considers that we don’t utilize partial hospitalization or intensive outpatient benefits at Sierra Tucson.

“John,” the admission mentioned above, was referred to us by an advocacy group that works with first responders. John had been going to outpatient for about six months, was unable to stop drinking, had been endangering himself and others by driving intoxicated, and had shown up to his public safety job under the influence. There were some additional co-occurring mood issues as well, and it was clear to anyone with an even moderate level of cognitive awareness that this individual needed significant clinical and medical intervention to prevent anything tragic from occurring.

The employer group involved in this case had decided to outfit their employees with what appeared to be very good mental health and substance abuse benefits. The plan had low deductible and coinsurance amounts and both in- and out-of-network benefits. Obviously these types of plans are far more expensive than most HMO or other baseline plans. While the particular insurance company involved had no issue in selling this plan to said employer group, it did take exception to allowing one of the group members to actually utilize the benefits sold. Residential treatment for John was denied. Sierra Tucson appealed and Chief Medical Officer Michael Genovese, MD, JD, personally handled the peer review. Once again, treatment was denied without one single day being authorized. The recommendation was that John return to the same outpatient level of care in which he was currently failing.

This sort of thing was common not so long ago but it wasn’t supposed to happen anymore. MHPA was passed in the 1990s and basically required that coverage levels (in terms of dollar amounts) provided to medical benefits also be available for mental health. Insurers responded by implementing day limits, higher deductibles on mental health services, and other restrictions on utilization of benefits. In 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed, which closed those loopholes but still did not explicitly require that plans offer coverage for mental health treatment; it only required that plans that offer both medical and mental health have equitable coverage levels. Finally, the Affordable Care Act classified mental health coverage as an “essential health benefit” and required that it be covered (still with some exceptions), beginning in 2014. So here we are with nearly all insurance policies including coverage for mental health and substance abuse, but no way to ensure that authorization of covered benefits is actually granted. In fact, many insurers employ completely arbitrary criteria guidelines and can still deny care regardless of clinical presentation.

This is exactly where we found ourselves with John. To be fair, there are some insurance providers that are quick to authorize care and seem to generally do the right thing. Additionally, very few cases are denied from Day 1 like John’s. Nevertheless, we were at a crossroads but decided as a team not to go down without a fight. It was at this point that I contacted one of our Treatment Placement Specialists for Acadia Healthcare and the referent who also happened to represent the employer group. We approached the problem from all angles. I, along with our utilization review manager, called the payer and we worked our way up the supervisory chain. The employer, who represents a very large employer group and also signs the premium checks, called and expressed his significant displeasure at the turn of events. Then he called again…and again. After a couple of days strategizing, our small team of amateur advocates was able to secure an initial seven-day authorization. This happened after the formal appeal process was exhausted. When all was said and done, John left residential treatment after 30 days were authorized.

This particular story ends well (I recently heard from the referent that John is thriving in sobriety), but this is only the beginning. The point here is that there is no real accountability for most of the major payers. We are the accountability. Some will argue for more regulation, others will say lack of competition in the insurance marketplace perpetuates this kind of practice. But really, neither matters in the near term. The reality is that, as providers, employers, and family members, we need to work together to collectively push back when arbitrary decisions are made that can endanger a resident’s or loved one’s life. It works. I have seen it work time and time again. It requires, however, that we all join forces. If we stay quiet, it is unlikely much will change anytime soon. We must remain optimistic, though. There is significant strength in numbers and we have the distinct advantage of knowing that what we are doing is right. As it says when one enters the front gate at Sierra Tucson: Expect a Miracle.