- Why use criteria?
- Use of criteria and GAF scores
- Structure of the Survey
- Phone calls and general information
Answers:
1. Why use criteria?
The Division of Health Care Administration from Vermont’s Department of Banking and Insurance, which is the state agency that oversees managed care in Vermont, requires that any plan working in Vermont use nationally recognized clinical criteria as guidelines in their utilization review activities. We chose ASAM because it was developed by providers and is the most recognized criteria for substance abuse work known throughout the country. We chose LOCUS for several reasons. The first reason is that it is a nationally known set of criteria. The second reason is that Stephen Cole who was a practicing psychiatrist in Vermont at the time (connected to both the Retreat and HCRS) had helped to author the criteria. Stephen was familiar with practicing behavioral healthcare in a rural setting. Finally several of the mental health centers in the state decided to use the criteria as a way of establishing a common language amongst them. We thought that both ASAM and LOCUS would be familiar to most of us working in the state.
Written into each of the criteria, the state regulations and our own policies, is the very clear belief that the criteria are employed only as a guide. The numbers do not dictate the level of care but make suggestions to be used along with clinical judgment.
2. Use of criteria and GAF scores:
Several providers mentioned that they had never really been trained in the use of criteria or how PrimariLink uses the GAF. This is an oversight on our part. We offered an in-service last year on the use of the criteria but did not follow-up with another one this past year. In truth, depending on the setting, some of us receive training in the use of clinical criteria and working with managed care and some do not. We would like to offer in-service training on how we use the criteria. If you are interested in a discussion about this topic, let me know. I’d be happy to travel to you and if you are part of a practice group, we could all meet over lunch.
3. Structure of the Survey:
It was noted that the survey was not scientifically structured. That is completely accurate. As you can tell, the questions are few and simple. What do you think of the criteria, the OTR and what’s it like working with us? We wanted it short and to the point. Unless there is a strong view from providers to add length, we’ll keep it short and sweet.
4. Phone calls and general information:
Under NCQA (National Committee for Quality Assurance) the national agency that reviews health plans, the requirements are simple. For clinical need/triage/access to care calls, the standard of answering the phone is under 30 seconds and the rate at which people “give up” and hang up should not exceed 5%. In 2002, (January-June) our phone rates were 12.3 seconds on average to pick-up on a clinical access call and the rate of abandoned calls was less than 2%. We do, however, have a general inquiry phone line and that does require callbacks. For those calling and needing access to care or an immediate answer, please hit #1 on the telephone prompt system. That will access an Intake Staff more quickly for you.
Comments about getting reliable information seem to relate to the lack of clarity about whether to ask MVP or PrimariLink your questions as well as getting different information on the same topic from MVP and PrimariLink. This is a good point and one that PrimariLink and MVP have recognized, particularly as it relates to claims payments. One of the solutions has been the way authorizations are now being entered into the MVP system. Other solutions have to do with PrimariLink joining several MVP committees to ensure that people answering the phones, from both MVP and PrimariLink give consistent and clear information. Please let us know if this is not getting better. We apologize if we’ve misled anyone with poor information. A rule of thumb would be; benefit questions go to MVP, clinical questions to PrimariLink.
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