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A recent survey of the rate at which managed care reviewers deny proposed specialty treatment for mental disorders has turned up far lower denial rates than experts had expected.
The survey data showed that managed care reviewers denied referrals from physicians to psychiatrists or mental health specialists in only 3 percent of cases, a denial rate equivalent to that for denials of all types of medical treatment.
This statistic represents the percentage of denials after a first-round appeal by the treating physician. First-round denials for specialized mental health treatment were reported by nearly 6 percent of physicians responding to the survey.
The study, conducted in 1995 by Dahlia K. Remler, Ph.D., of Tulane University’s School of Public Health and Tropical Medicine, and researchers at Harvard University and Louis Harris and Associates, surveyed 2,003 U.S. physicians about how managed care techniques have affected the way they practice and what proportion of their patients are covered by managed care.
The study discovered that generalist physicians had a harder time obtaining approval for specialized mental health care for their patients than did specialists. Managed care reviewers initially rejected referrals for mental illness treatment in 8.3 percent of the patients treated by general physicians, but denied such care in only 5.5 percent of the patients seen by specialists. About half of these first-round denials were reversed once the physicians invoked the appeals mechanism.
Physicians who believed that a patient needed to be referred for treatment of a substance abuse disorder were denied the opportunity to do so in 2.8 percent of cases following one appeal to the managed care company, with 4.2 percent having been denied initially.
Despite the relatively low rate for denying referrals for mental illness treatment, it was still the type of care for which insurance coverage was most often denied, followed in order by substance abuse care and referral to "a specialist of choice."
For all types of care about which the physicians were questioned, the rate of denials by managed care reviewers was 6 percent; after the first round of appeals, the rate dropped to 3 percent, almost identical to the numbers for mental health treatment. Requests for MRI tests were rejected by reviewers in 2.1 percent of cases, surgical procedures in 1.2 percent, and hospitalization in 1 percent, the researchers found.
Remler and her colleagues also reported that although a majority of physicians stated that they had experienced no care denials by managed care reviewers, 5 percent of physicians said that coverage for recommended treatment was denied for 20 percent or more of their patients.
The survey data, which are reported in the fall issue of the journal Inquiry, showed that 59 percent of patients treated by the responding physicians were in plans using utilization review, while 38 percent of patients had insurers who required physicians to accept discounted fees.
These survey data appear to contrast significantly with the degree to which physicians express concerns about how managed care denials are interfering with their ability to deliver quality patient care. A survey of physicians’ attitudes toward and problems with managed care conducted by the same research team found that 39 percent were troubled by managed care limitations on ordering diagnostic tests and procedures, while 31 percent complained of limitations on prescribing drugs they select, and 41 percent are dissatisfied with the limitations they face when trying to hospitalize their patients. In addition, 40 percent reported that they confronted managed care obstacles when they tried to refer patients to a specialist. The results of the attitude survey are reported in the September/October 1997 issue of Health Affairs.
On all of these practice concerns, physicians in states with at least 35 percent managed care penetration expressed more distress over the limitations on their decision-making authority than did their colleagues in states with low managed care penetration, which the researchers defined as less than 11 percent of insured patients.
Despite the surprisingly low rates of managed care or utilization review denials for mental health and other forms of medical care, Remler noted that it should not be assumed that these trends, which have so dramatically altered the health care landscape, have had minimal impact.
A factor not assessed in these surveys is that these reviews may in fact "discourage physicians from proposing care for which they expect the insurer will deny coverage. That is, [managed care reviews] may have a deterrent or sentinel effect," she pointed out.