State pilots vary in EWP use
Pennsylvania developed an early warning program (EWP) to provide oversight for its behavioral health managed care program. Service authorization data that were collected identified some counties with low rates of authorizations for services compared with adjacent counties. This was seen in several service categories, including outpatient mental health services and intensive case management. Authorizations increased after it was found that there weren’t enough providers and additional providers were recruited.
A discrepancy also was seen between the percentage of African-Americans authorized to receive mental health services relative to other populations. State officials assumed that distribution of mental illness and the need for behavioral health services was equal among all groups and suspected that the low service authorization numbers reflected barriers to care. The county and contracted managed care organization started actions to ensure that access to needed services was improved for this minority group.
In reviewing claims payment data, Pennsylvania officials identified problems with one managed care organization’s payments to providers. The state requested and received a plan of correction that included advancing funds to providers with cash-flow problems, hiring additional staff, developing educational forums to assist providers, and modifying policies for dealing with third-party benefits, which had been delaying provider payments.
Data derived from the EWP’s grievance measure showed that one managed care organization had more than 50% of grievances denied. Follow-up revealed that the denials were related to providers’ untimely submission of clinical information to the managed care organization. When the submission procedures were corrected, there was a 67% drop in the percentage of denials that were grieved.
In Vermont, an EWP was developed to oversee the Community Rehabilitation Treatment program that managed care for 2,700 serious mentally ill adults statewide. One of the measures used in this program was average client service hours, and considerable variation was found from agency to agency during the first full year of case rate payments. The average number of service hours used for beneficiaries in community agencies with high average service hours declined after introduction of case rates, while there was little change of hours in agencies with lower average service hours. State officials saw this shift as one of the desired outcomes in the introduction of case rates.
One of the top priorities for state officials was to reduce the rate of involuntary commitments. Using the EWP, the state was able to monitor this activity for the first time. Also, the number of program participant admissions for inpatient services was an EWP measure. Hospital admissions declined 43% during the first year of the program, suggesting to state officials that the program was limiting the need for hospital admissions and that needed services were being provided in the community.
Washington, DC, started its EWP to assure that health services in a waiver program that began in April 1998 were available as intended and that problems were addressed quickly. Member complaint data allowed the District to quickly identify and ameliorate problems with beneficiary primary care provider selection and pharmacy benefits. The District also used data from proxy telephone calls to improve access to treatment providers.
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