The goal of this project was to study the process by which treatment authorization decisions are made for children's mental health services in Arizona in order to organize citizens in the community to lobby for improvements.
To this end, NMHA collected materials from both the public and private sector, including the level-of-care criteria from the companies that provide mental health services to Arizona's largest employers (and thus their employees and dependent children):
- Cigna Behavioral Health (formerly MCC Behavioral Care),
- Horizon Behavioral Health Services, and
In addition, NMHA gathered medical necessity definitions and level-of-care criteria from each of the state's five public sector Regional Behavioral Health Authorities (RBHAs). These definitions were not compared for the private sector because the vendors either: (1) did not use them, relying solely on level-of-care criteria for treatment authorization, or (2) used different definitions across their book of business, depending upon their clients' wishes. The medical necessity definitions we studied were thus from the following RBHAs and counties:
- Value Options (Maricopa County);
- Community Partnership of Southern Arizona (Pima, Cochise, Graham, Greenlee, and Santa Cruz counties).
- The EXCEL Group (Yuma and LaPaz counties);
- Pinal Gila Behavioral Health Association (Pinal and Gila); and
- Northern Arizona Regional Behavioral Health Authority (Coconino, Mohave, Yavapai, Navajo, and Apache counties).
We also obtained the statewide Arizona Level of Functioning Assessment/Service Level Checklist.
A panel of parents, clinicians and policy experts was next assembled to discuss the content of all materials, which were distributed in advance to allow for a thorough review. (A full listing of the panel members, including their brief biographies, is contained in the inner cover of this publication.) The panel was asked to pay special attention to the following areas:
- Any particularly positive and/or negative practices that stand out;
- Expansions/revisions that should be made to medical necessity definitions;
- Clarity of the criterialack of "wiggle" room for the clinician's interpretation and judgment;
- Consistency with national standards of practice;
- Attention to optimizing and improving level of functioning;
- Attention to individual and family strengths and needs, as well as cultural considerations; and
The panel then gathered for an all day meeting, and thoroughly reviewed each criteria set, statewide policy document, and medical necessity definition. It is important to note that this was a qualitative, rather than a quantitative, review process. The panel first analyzed the similarities and differences between the various medical necessity definitions, citing recommended revisions (largely expansions). The panel next reached consensus on recommended revisions to statewide policy documents. Finally, the panel agreed upon a list of the most important substantive areas for comparing the level-of-care criteria sets, as well as recommended revisions. These final deliberations focused on two main areas:
- Operating philosophy
Policies Obstructing Access (including specific areas identified for revision or expansion)
- Attention to the special needs of children
- Meaningful involvement of families
- Emphasis on strengthsnot deficits
- Emphasis on quality and value, versus cost containment
- Attention to cultural issues
- Other notes (issues related to general approach and philosophy)
This report is the resulting summary of all these deliberations.