Prior authorization (PA) goes by many names—preauthorization, preapproval, advance notification, precertification and preadmission, to name a few. All these terms refer to the utilization management (UM) process used by many U.S. health insurance companies to ensure patients receive the right services, equipment and prescriptions at the right time and place. PA requires healthcare providers to request and obtain approval before rendering certain services, equipment or prescriptions in order to receive insurance reimbursement for those services. Not everything requires PA. Typically, authorization is needed for more complex services such as hospital admissions, diagnostic tests, medical equipment and complex prescription medications.

The PA process is intended to act as a safety and cost-saving measure. It can lower costs to the patient, prevent unnecessary or invasive procedures, and reduce the use of unnecessary tests that may expose patients to potentially harmful radiation and/or undue stress. For example, up to half of advanced imaging procedures ordered fail to provide information that improves patients’ welfare.[i] In addition, despite studies demonstrating overuse, rates of advanced imaging procedures continue to rise—increasing costs and exposing consumers to excessive radiation.  Despite its benefits, the prior authorization process needs an upgrade.

According to the 2018 CAQH Index , manual prior authorizations (via fax or telephone) are the second most-costly medical administrative transaction, costing providers $6.61 per submission. Providers estimate their staff members spend up to 30 minutes completing one manual prior authorization. While manual prior authorization is a much-debated topic due to the time and cost it requires, many parties support standardizing and simplifying the process.

Technology can significantly  decrease the need for expensive manual processes.  According to the 2018 CAQH Index, the medical industry could save $417 million annually by transitioning to electronic prior authorizations, which includes $278 million in annual savings for providers and $139 million for health plans.

While many health plans offer web portals to process prior authorizations, this approach requires providers to use different online systems for each health plan. Instead, digital solutions should include automation within the electronic health record (EHR) and the physician’s workflow. Automation is essential to reducing inefficiencies for providers and health plans and enabling authorizations at the point of care while maintaining clinical integrity.

The goal is to make the right decision for each patient—quickly and easily so patients get the care they truly need. Automating prior authorizations will benefit everyone involved.

[i]Beachy, D. (2014, September 8). Defensive medicine driving up wasteful imaging. Retrieved from https://www.healthimaging.com/topics/healthcare-economics-policy/defensive-medicine-driving-wasteful-imaging.

As we observe National Minority Mental Health Awareness Month, we sat down with Dr. Rakel Beall-Wilkins, a former Magellan Healthcare medical director.

 Magellan Health Insights: Dr. Beall-Wilkins, thank you for speaking with us today. Of course, everyone’s mental health is critical, but why is it important to pay particular attention to the mental health of Black, Indigenous and People of Color (BIPOC)?

Dr. Rakel Beall-Wilkins: We know that mental health conditions can be successfully treated. However, BIPOC are significantly less likely to receive treatment for mental health conditions, including substance use. And it’s reaching crisis levels, especially among our young people. For example, suicide is now the third leading cause of death among African American males who are 15-24 years old.

Magellan Health Insights: What are the barriers to BIPOC receiving high quality mental health treatment?

Dr. Rakel Beall-Wilkins: BIPOC are less likely to seek treatment, both for their physical and mental health. However, when they do reach out for assistance, they are less likely to receive consistent, high-quality treatment.

There are many contributing factors to these barriers. The high costs of care can be a deterrent. Most BIPOC in the U.S. (with the exception of Asians) have higher than average rates of poverty. BIPOC are more likely to lack insurance coverage, and may only seek emergency care, which costs more and is less effective than sustained treatment. Medications or diagnostic procedures may be viewed as too expensive. Or reliable transportation for follow-up care may not be available.

There are also what are called the social determinants of health (SDoH). These include factors such as consistent transportation, the availability of healthy food, safe and affordable housing, access to education, public safety and working conditions. BIPOC are more frequently negatively impacted by the SDoH. For example, these members are more likely to be homeless or move frequently, which interferes with maintaining consistent treatment. They may lack adequate nutrition and are at greater risk for having associated medical conditions like hypertension or diabetes.

Further, the stigma around mental health conditions, while improving, is still a deterrent to seeking treatment—for everyone. Some cultures may see it as taboo to request help or be seen as someone who needs help.

When BIPOC patients do seek treatment, there may be no one available who speaks their language. In some clinical settings I’ve been in, it could take a week to arrange for an interpreter or a therapist who was proficient in the patient’s language. They may not have a primary care physician (PCP) to help with screening for mental health conditions or provide follow-up care. In addition, the community clinics where BIPOC are more likely to receive care may be understaffed, overcrowded and have long wait times. Understaffing may lead to inadequate screening or even misdiagnosis. And, frankly, the clinic also may not be in a place where the member feels safe traveling so, they may hesitate to go in the first place or return for continued treatment.

Magellan Health Insights: How can everyone, including healthcare professionals, best support minority mental health?

Dr. Rakel Beall-Wilkins: Everyone can help eliminate stigma. Be open to talking and hearing about mental health conditions, and make it clear that you know that having a mental health condition is nothing to be ashamed of. When someone you care about is going through a difficult time, encourage them to get help, and learn ways you can support someone who coping with a mental health challenge.

As healthcare providers, we personally can help by:

• Ensuring we are taking into account each person’s wishes when referring them to other providers: We should ask every patient whether they prefer to see someone of a specific race, ethnicity, gender or sexual orientation.
• Educating ourselves to be more culturally competent and making cultural training a priority for our staff.
• Expanding our workforces with staff from various backgrounds, sexual orientations, cultures and with varied linguistic skills particularly for the unique cultures that are most prevalent in the community.
• Screening for psychiatric conditions during routine visits. Many patients will report physical symptoms instead of talking about the underlying mental health concerns. PCPs and others see many cases of mild or moderate depression during routine care, and screening every patient can help prevent costly emergency visits and admissions. Self-screening tools can also help.

Beyond what we can personally do to educate and equip ourselves and our staff, I believe that the best solutions come from an integrated, collaborative approach. Everyone can help eliminate the disparities. If we work with leaders in the community, for example in churches and schools, we can raise awareness of mental health conditions, destigmatize treatment seeking, help address the social determinants, and improve the lives of everyone in our communities.

Care is core to every service we deliver and everything we do at Magellan Health. Through our work, we are listening, learning and using our collective insight to make a difference in the lives of those we serve.

Wyoming’s High Fidelity Wraparound program is just one of many examples where Magellan team members, who have lived through similar experiences, are returning the favor and providing the care and concern they consider themselves fortunate to have also personally received.

High Fidelity Wraparound is a voluntary planning and care coordination process for children and young adults (ages 4-20) with complex behavioral health conditions. High Fidelity Wraparound’s community-based solutions and planning process bring people together from different areas of a family’s life to form a team. The team, led by a Family Care Coordinator, creates steps to help youth stay in their homes, schools and communities.

Through collaboration with the Wyoming Department of Health, Division of Healthcare Financing (Medicaid), Magellan serves as the Care Management Entity for the High Fidelity Wraparound program, setting the rules and providing training for everyone involved in the process.

One of Magellan’s certified Family Care Coordinators, a person responsible for managing a High Fidelity Wraparound team, recalls the story of a recent family she worked with. “In December, the family’s generator went out and without power they had to leave their home. As a result, the family had to move which was highly disruptive and caused a lot of tension within the family as their culture is centered on independence. In addition, it was upsetting to a young member of the family as the unfamiliar environment became very troubling.”

Living away from home negatively impacted progress the youth was making before having to move. Relationships were being affected and everything for this youth became more difficult. The family requested help to get back to their property through Magellan of Wyoming. Their Family Care Coordinator said, “When we found out our flex funds were approved to help get them home, [mom] cried and I did as well. This family finally felt hope, and there could now be a clear plan to help them move back home.”

Tammy Cooley, senior operations director at Magellan Healthcare of Wyoming, said, “We are honored to provide a means for a family to get back to their home, and keep their youth with them. Sometimes, we see families in situations where youth cannot remain at home. When we can fill a need and keep a youth safely at home because it’s the right thing to do, we will do that. The work we do, at the very core, is about the success of youth and families being able to meet their needs in positive ways.”

What are social connections?

Social connections are the relationships you have with the people around you. They may be close, like family, friends, and coworkers, or more distant, like people you know casually. They can be as close as next door or so far away that you only connect with them by telephone or through the Internet.

Your network of relationships may be big or small. One or two close family members or friends may be all you need to feel supported and valued. Whether your circle is big or small, the important thing is that you are there for each other.

Why are social connections important?

Resilience, the ability to bounce back after stressful situations, is strengthened when you give and receive support. Building positive relationships with people can make a difference in how resilient you are. Try to connect with people who have a positive outlook and can make you laugh and help you. The more positive your relationships are, the better you’ll be able to face life’s challenges.

The support you get from your social connections can add to your feelings of meaning and purpose in life. These, in turn, add to your resilience. Happy, resilient people tend to be more connected to the people around them. Resilient people know that they can depend on the strength of their family and friends when the going gets tough.

Remember that giving support is just as important as getting support. You count on your social connections for support, but they also count on you. Ask others about their families, jobs, and interests, and help them when you can. Don’t always focus on your challenges or talk about yourself. Know when it’s time to listen or just enjoy your friends’ company. Giving support to others builds the social bonds that help make you resilient.

 How can you make more social connections?

There are many ways you can start building positive relationships:

• Invite a friend who makes you laugh, and go to a funny movie.
• Send an encouraging email or text message to someone who’s going through a hard time.
• Look for a faith community that shares your views. It may also have its own organized social groups.
• Call a food bank or hospital and ask about their volunteer programs.You can also connect with people through social media on the Internet. Many people interact more freely with people they can’t see face-to-face. Online forums about specific interests can be a good choice for people who cannot leave their homes or are shy or self-conscious.

©1997–2019, Healthwise, Incorporated

Read the full article here: https://www.healthwise.net/magellanhealth/Content/StdDocument.aspx?DOCHWID=abl0295

Overview

Post-traumatic stress disorder (PTSD) is a mental health disorder. Many people believe things about mental health disorders that aren’t true. Here are some myths about PTSD.

Myth: PTSD is in your head. It does not exist.

PTSD does exist. It is a recognized mental health problem that has been studied for many years. You may get PTSD if you have lived through a traumatic event that caused you to fear for your life, see horrible things, and feel helpless. Strong emotions caused by the event create changes in the brain that may result in PTSD.

PTSD has not always had the same name. It also has been called combat fatigue or shell shock.

Myth: Only soldiers or people in war zones get PTSD.

Anyone who sees or goes through a traumatic event can develop PTSD. A traumatic event is a horrible and scary experience. During this type of event, you think that your life or others’ lives are in danger. You feel that you have no control over what is happening. These events include violent crimes, sexual assaults, childhood neglect or abuse, and natural disasters such as hurricanes or earthquakes. Your job also could expose you to traumatic events. First responders at a traumatic event, such as firefighters and police, can develop PTSD.

Myth: You should be able to move on after a traumatic event.

The strong emotions you may feel during the traumatic event can create changes in your brain that result in PTSD. You may not be able to “move on” because of this. It’s important to remember that PTSD is a medical condition. People with other health conditions, such as cancer, deal with the condition as best they can. The same is true for PTSD.

Myth: PTSD always happens right after the traumatic event.

PTSD symptoms can develop at any time after a traumatic event. Your symptoms may start soon after the event, or you may not have them until months or years later. They may come and go over many years.

Myth: People with PTSD cannot function.

PTSD can cause severe symptoms, but counseling, medicines, and support all help people adjust. People with PTSD have jobs and relationships. They enjoy life and are active members of their communities.

To view this article on Healthwise, click here

©1997–2019, Healthwise, Incorporated

When the whole family is involved in physical activities together, children learn that being active is fun and makes you feel good. And busy parents can combine family time with exercise time.

Try these tips for getting everyone in the family up and moving together:

Getting started

• As a family, make a list of activities you’d like to do together.
• Make sure the activities are things everyone can do and enjoy.
• Keep a family physical activity log, or hang a calendar on the wall.
• Try to plan one or two family activities a week. For ideas, see the suggestions below.
• Once a month, plan something special that involves being active, like a trip to the zoo, a day hike, or camping.
• Use a safe backpack, stroller, or bike trailer so that smaller children can be included in family activities.

Walking

When family schedules get really busy, going for a walk may be the easiest thing you can do together.

• Start with short walks that everyone in the family can do. Add more distance gradually. Younger children can ride a bike or a tricycle. You can pull a wagon in case little ones get tired.
• Scavenger hunts can keep children from being bored on a walk. Keep in mind a list of “treasures” they can find, such as a red leaf, a blue house, a black dog, or an out-of-state license plate.
• Use a phone app or get pedometers, and work on increasing the number of steps you take on your family walks. Start with a goal of 10,000 steps a day.
• Register the whole family in a family fun run/walk in your community. If the event is for charity, have your family walk through your neighborhood to collect pledges.

Outdoor activities

• Go for a bike ride.
• Join your children in old-fashioned games like hopscotch, tag, jump rope, and hide-and-seek.
• Get involved in family-friendly sports like skiing, skating, swimming, and tennis.
• Play a daily family basketball game in the driveway or at a playground.
• Take up miniature golf or flying-disc golf.
• Fly a kite.
• Pick up trash at a local park.

Indoor and rainy-day activities

• Have a family dance night. Share dances from each generation, and teach each other to do them. Or learn folk dances.
• Create a new dance or exercise routine to a favorite song. Have a different child choose the song each week.
• Go to the mall, and count how many laps you can walk as a family.
• Have a hula hoop contest.
• Set up a fun obstacle course in the basement, garage, or spare room.

General rules

• Limit TV, video games, and computer time.
• Don’t use food as a reward for meeting activity goals.
• Make physical activity a priority. Don’t let things get in the way of family activity time.

To view this article on Healthwise, click here

©1997–2019, Healthwise, Incorporated

Patient management programs are important for both payers and patients. Successful patient management programs can improve health outcomes and quality, increase member enrollment, and improve member satisfaction, all of which support the health plan. The goal of a successful patient program is to improve the quality of medication use and the overall health and wellness of the patient, and this can be achieved through patient engagement and empowerment.

Knowing all of this, the challenge for a patient management program is often getting patients to participate. Traditionally, this has occurred through live and/or automated telephone calls and mailed letters to the patient, and additional faxes to the patients’ providers. These approaches have varied engagement results, and there are growing concerns that there is a ceiling to how many patients can be engaged through these modalities.

Adults are working longer into life than ever before, making them harder to reach and talk to during traditional business hours. In addition, letter campaigns become more and more costly as postage rates continue to rise, and a growing interest in “going green” makes mass mailings appear wasteful.

Newer technologies and the prevalence of mobile devices present new opportunities to engage patients, particularly the millennial generation that are now becoming patients themselves.

Today’s patient likely has a smart phone and may also have a tablet and/or wearable device, all of which provide a means to communicate with his/her provider(s). With that in mind, here are several ways that patient management programs can evolve using technological advances:

Text Messaging – Text messages have become the go-to method of communication for many people. Responses can typically be received in a matter or minutes, and even “busy” patients can text when a phone conversation may be a non-starter. Beyond one-way alerts and reminders to the patient, two-way exchanges and even live chat features are available.

Video Conferencing – For patients who may be not wish to text, online video capabilities allow for face-to-face counseling between clinicians and patients, even if that consultation isn’t in a conventional setting. As opposed to telephone calls, video chats allow for perception of non-verbal cues, assessment of physical symptoms, and even walkthrough tutorials, like injection training.

Artificial Intelligence (AI) – AI can range from predictive modeling and analysis used to predict potential adherence issues, to apps that can monitor, track, and measure adherence through features like facial recognition, digital pills, and more.

Video on Demand – Consumption of video content via mobile devices is as common as ever, and there are services available which can provide patients with additional drug information that can accessed whenever, wherever. These videos can reinforce talking points covered during consultation and provide a compliment to education provided through patient management programs. It also allows for information to be shared in a paperless way.

There’s nothing quite like a good comeback. It’s a testament to the determination of the human spirit, and a reminder of why second chances can be a great thing. The beauty of a comeback is that it happens in many forms. It could be an athlete getting back on the field after a major injury, or a determined older student going back to school to finally earn their degree. For Adam McCullough, it’s finding his way back into the driver’s seat.

For most of his life, Adam, 28, lived without a disability. He grew up in Holmen, WI, and played college football at Macalester College in St. Paul, MN. After graduating, he got a job at the Minnesota Department of Agriculture as a hydrologist, where he’d gather samples of water from lakes and rivers and test what was in them. But on December 26, 2016, Adam was driving home and crashed his car after hitting an icy patch on the road. The accident left him paralyzed from the chest down.

At first, Adam’s main focus was learning how to navigate life in a wheelchair. Simply getting around his parent’s home on his own was a challenge. He set his sights on building strength through physical and occupational therapy, and took part in trial studies for new treatments. Over time, he regained some movement in his hands. As he became more independent, he realized just how much he missed driving.

“Little things pop in your head,” says Adam. “If I want to go to the grocery store by myself, I just don’t have that option. It’s been limiting, you know? I think anyone can picture that.”

Having made so much progress in other areas of his life, he started wondering if there was a way he’d be able to drive again. After talking with his doctor and doing some research, Adam told his TMG IRIS Consultant, Julie, of his new goal. They started this journey by first getting Adam an accessibility assessment to see what he would need to do to drive again. They then got Adam a learner’s permit so that he could practice driving an accessible vehicle. Adam also needed to take a driver assessment to determine the exact equipment he would need in his vehicle so that he could safely and easily drive. Finally, he will have to pass the Division of Motor Vehicles (DMV) road test to get his license.

Through it all, Adam and Julie have worked closely together. They spent time looking into funding options to cover the driving assessment and equipment, and options to purchase a van. Even when the road got long, they knew that together Adam could reach his goal.

“Julie is there every step of the way,” says Adam. “We educated ourselves and researched everything together. Without Julie, I wouldn’t be talking to you [about driving] right now.”

Of course, Julie is quick to say that Adam has been the driving force behind making all of this happen. His grit and persistence to get back to driving and regain independence is amazing, and she says it’s been wonderful to watch him continue to make progress in many different areas of his life.

“Adam has a passion for self-direction,” says Julie. “He’s coming to me saying ‘This is what I need, this is what I want.’”

In January, Adam was finally able to drive for the first time in two years when he test drove accessible vans to figure out which equipment worked best for him. The driving consultant feels confident that, after a few more sessions, Adam will be able to pass the DMV’s road test and get his driver’s license. He says he was thrilled to be driving his dad around for a change.

As Adam gets closer to getting his license, he’s excited for all the possibilities that will open up. Driving his dogs out to the dog park; getting himself to work on his own; visiting far-away friends. However, more than anything else, he’s simply excited to be behind the wheel again.

“When I get the car, I’ll turn the radio volume up all the way and just drive around by myself for an hour,” says Adam. “My dog will have her head out the window. Me just driving around and torturing people with my singing voice!”