New systems to manage mental health care

The impact of managed care on substance abuse treatment: a report of the American Society of Addiction Medicine

This report examines the impact of managed care (MC) and related developments on substance abuse treatment, and evaluates how it has been associated with a decline in the availability of proper treatment for many addicted patients. A trend toward carve-out and for-profit MC organizations is associated with lower financial incentives for intensive treatment than in earlier staff-model and not-for-profit MC organizations. The value of substance abuse insurance coverage has declined by 75% between 1988 and 1998 for employees of mid-to large-size companies, compared with only an 11.5% decline for general health insurance. The shift towards MC has also been associated with a drastic reduction in frequency and duration of inpatient hospitalization, and there is no clear evidence that this reduction has been offset by a corresponding increase in outpatient support. In a survey of physicians treating addiction, the majority felt that MC had a negative impact on detoxification and rehabilitation, and on their ethical practice of addiction medicine.

Mental health and managed care

Managed care has become the dominant method for financing and delivering care for common mental health problems and for people with severe, chronic mental health conditions. Despite the rapid growth of managed mental health care, there is very little research available to guide policy choices. Managed care has led to decreased costs for employers and other payers, mostly through reducing hospital admissions or length of stay. Managed care organizations use staff with lesser levels of training (e.g. social workers instead of psychiatrists) and are more likely to offer group outpatient programs and manualized treatment than their fee-for-service counterparts. Despite these differences, there is no clear evidence that health outcomes are worse for patients in managed care. There is an urgent need for researchers to turn their attention to issues such as cost, quality, access, satisfaction, and functional outcomes associated with managed mental health care. The impact of parity of mental health with insurance coverage for physical conditions is another important question that needs to be addressed.

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

The growth of managed care has led to greater cost consciousness in the financing and delivery of mental health and substance abuse services. The authors examine whether pressures to reduce the costs associated with mental health and substance abuse treatment have led to the overapplication of a popular managed care strategy, utilization review (UR), to the management of outpatient psychotherapy benefits. Several arguments are presented highlighting why changing outpatient psychotherapy UR practices would be in the best economic and clinical interests of all involved parties, including payers, managed care organizations (MCOs), mental health consumers, and providers. A number of alternatives to the aggressive management of outpatient psychotherapy benefits are outlined and discussed.

Public managed care: the role of the consultant

Consultants will be increasingly important as public systems retool to fund and monitor managed behavioral health care services. Medicaid agencies, heretofore limited primarily to paying claims, must now develop expertise in RFP preparation and managing contracts.

Managed care in mental health: the ethical issues

Praise and blame of managed mental health care are on the rise on many fronts, including allegations that it could adversely affect quality of care, access to care, the physician/patient relationship, and informed patient choice. Given the heterogeneity among managed mental health care organizations--each with differing practices--it is difficult to sift the ethically defensible concerns from the indefensible ones. In this paper we identify and examine the different moral concerns about managed mental health care and mark which problems have been addressed or are in need of resolution. We also identify which problems are unique to managed mental health care.