An economic and clinical rationale for changing utilization review practices for outpatient psychotherapy

Changing mental health gatekeeping: effects on performance indicators

This study evaluated how a change in gatekeeping model at a health maintenance organization affected performance indicators for specialty outpatient mental health care. Gatekeeping in one division changed from in-person evaluations to a call center with routine authorization for the first eight visits. Using 1996-1999 claims data (including 2 years pre- and 2 years postintervention), the study compared performance indicator results in the affected division and another where the model did not change. Subjects included 122,751 continuously enrolled persons. Dependent variables were mental health emergency room use, treatment initiation, treatment engagement, and family treatment for child patients. After controlling for secular trends at the other division and enrollee characteristics, the division that changed gatekeeping experienced no significant impact on most indicators and an increase in family treatment for children. The move to call-center gatekeeping did not appear to have a negative impact on treatment process as reflected in these indicators.

Does type of gatekeeping model affect access to outpatient specialty mental health services?

OBJECTIVE

To measure how a change in gatekeeping model affects utilization of specialty mental health services.

DATA SOURCES/STUDY SETTING

Secondary data from health insurance claims for services during 1996-1999. The setting is a managed care organization that changed gatekeeping model in one of its divisions, from in-person evaluation to the use of a call-center.

STUDY DESIGN

We evaluate the impact of the change in gatekeeping model by comparing utilization during the 2 years before and 2 years after the change, both in the affected division and in another division where gatekeeping model did not change. The design is thus a controlled quasi-experimental one. Subjects were not randomized. Key dependent variables are whether each individual had any specialty mental health visits in a year; the number of visits; and the proportion of users exceeding eight visits in a year. Key explanatory variables include demographic variables and indicators for patient diagnoses and their intervention status (time-period, study group).

DATA COLLECTION/EXTRACTION METHODS

Claims data were aggregated to create analytic files with one record per member per year, with variables reporting demographic characteristics and mental health service use.

PRINCIPAL FINDINGS

After controlling for secular trends at the other division, the division which changed gatekeeping model eventually experienced an increase in the proportion of enrollees receiving specialty mental health treatment, of 0.5 percentage point. Similarly, there was an increase of about 0.6 annual visits per user, concentrated at the low end of the distribution. These changes occurred only in the second year after the gatekeeping changes.

CONCLUSIONS

The results of this study suggest that the gatekeeping changes did lead to increases in utilization of mental health care, as hypothesized. At the same time, the magnitude of the increase in access and mean number of visits that we found was relatively modest. This suggests that while the change from face-to-face specialty gatekeeping to call-center intake does increase utilization, it is unlikely to overwhelm a system with new demand or create huge cost increases.

Managed care organizations' use of treatment management strategies for outpatient mental health care

A nationally representative sample of managed care organizations was surveyed (response rate=92%) regarding use of treatment management techniques for outpatient mental health care in their commercial products in 1999. Bivariate tests and logistic regression models were used to examine the relationship between product type, behavioral health contracting arrangement and treatment management techniques (prior authorization, standards for time to initial appointment, concurrent review, standards for follow-up after discharge, case management, practice guidelines). Prevalence varied from 43% to 87% depending on the technique. HMO products and products with specialty behavioral health contracts were more likely to use the techniques. Product type and contracting arrangement had independent effects.

Does managed mental health care reallocate resources to those with greater need for services?

Evidence points to the existence of two coexisting inefficiencies in mental health care resource allocation: those with need receive too limited or no care while those with no apparent need receive services. In addition to reducing costs, managed mental health care is expected to reallocate treatment resources to those with greater need for services. However, there are no empirical findings regarding this issue. This study tests whether managed mental health care has had a differential impact by level of need. Data consist of three waves of a community sample with a control group. The study finds that managed care has not succeeded in reallocating resources from the unlikely to the definite "needers."

The impact of prior authorization on outpatient utilization in managed behavioral health plans

This study examines how preauthorization affects outpatient behavioral health utilization under managed care by comparing plans with similar benefits, but differing in the number of visits authorized. The authors compare plans primarily authorizing in increments of 5 visits to plans authorizing in increments of 10 visits. They analyze the likelihood of terminating outpatient service between the two groups using conditional logistic regression. Results suggest that patients whose treatment is authorized in increments of 5 sessions are nearly 3 times more likely to terminate treatment at exactly the fifth visit than if their treatment is authorized in increments of 10 sessions conditional on being in treatment until the 5th visit. The likelihood of termination peaks in both the 5- and 10-session authorization at the 10th visit, but the difference is not statistically significant. The authorization effect differs by provider type and is weaker among psychiatrists than among nonphysician providers.