Academic psychiatry and managed care: a case study

Substance use disorders and employability among welfare recipients

The 2006 welfare reform legislation (Deficit Reduction Act of 2005) imposed more stringent work requirements and defined the amount of time cash assistance recipients are allowed to be exempted from the work requirement because of substance use treatment. As there is little empirical literature on the employability of substance users, it is difficult to know whether it is realistic to expect individuals with substance use disorders to meet the increased work requirement. Based on a comprehensive evaluation of nearly 9,000 substance-misusing welfare recipients from 2001 to 2007, University Behavioral Associates (UBA) Comprehensive Services Model program in Bronx, New York, found that 60% of recipients were not exempted from the work requirement owing to substance misuse at the outset, and an additional 24% were found nonexempt after 3 months of intensive outpatient treatment coupled with case management, resulting in a total of 84% of the UBA clients not being exempted from the work requirement because of substance misuse by Day 90. UBA also found that 25% of substance-misusing clients were able to obtain employment, and most successfully retained those jobs over the course of 6 months. These findings are discussed in relation to the new law's work requirements and the issue of the employability of substance misusers. Finally, the value of case management in serving this hard-to-engage population is discussed.

Financial management challenges for general hospital psychiatry 2001

Psychiatry programs are facing significant business and financial challenges. This paper provides an overview of these management challenges in five areas: departmental, hospital, payment system, general finance, and policy. Psychiatric leaders will require skills in a variety of business management areas to ensure their program success. Many programs will need to develop new compensation models with more of an emphasis on revenue collection and overhead management. Programs which cannot master these areas are likely to go out of business. For academic programs, incentive systems must address not only clinical productivity, but academic and teaching output as well. General hospital programs will need to develop increased sophistication in differential cost accounting in order to be able to advocate for their patients and program in the current management climate. Clinical leaders will need the skills (ranging from actuarial to negotiations) to be at the table with contract development, since those decisions are inseparable from clinical care issues. Strategic planning needs to consider the value of improving integration with primary care, along with the ability to understand the advantages and disadvantages of risk-sharing models. Psychiatry leaders need to define and develop useful reports shared with clinical division leadership to track progress and identify problems and opportunities. Leaders should be responsible for a strategy for developing appropriate information system architecture and infrastructure. Finally, it is hoped that some leaders will emerge who can further our needs to address inequities in mental health fee schedules and parity issues which affect our program viability.

Outcomes focused service delivery: developing an academic-management partnership

OBJECTIVE

Current mental health policies emphasise the need for services to be integrated and to develop outcomes-based evaluation systems. An overview of the challenges faced by service managers and clinical academics who develop the appropriate financial, personnel and academic infrastructure for these tasks is presented.

METHOD

By drawing on experiences within the St George Service and references to other services, we propose a model for a successful partnership between the academic and management components of a district service.

RESULTS

Major logistic impediments to the development of a partnership are identified, although the long-term scientific and service delivery benefits are highlighted. Key areas within both academic practice and managerial approaches requiring transformation are discussed.

CONCLUSIONS

A successful long-term partnership between management and an academic department within a district service may provide the opportunity for rapid progress in population-based service evaluation and health outcomes research.

A new approach to managed care: the provider-run organization

Behavioral managed care has been dominated by for-profit carve-out managed care organizations who deliver mental health and substance abuse services by reducing services and fees to the detriment of patients and providers. We offer a new model of managed care based on a provider-run, hospital-based approach in which provider groups contract directly with HMOs and eliminate the managed care organization intermediaries. This approach allows providers to maintain or regain control of the delivery of behavioral health services. A model is presented of an academically based organization which has achieved utilization patterns compatible with the demands of payors. Innovations in service delivery, network management and fiscal issues are reviewed.