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Whatever its flaws, managed mental health care exists because prior ways of providing care failed to solve problems of cost, quality, and access, according to a briefing by the Alliance for Health Reform (AHR) held in Washington, D.C., last month.
The briefing brought together panelists representing the National Alliance on Mental Illness (NAMI), the actuarial firm Lewin Group, the American Managed Behavioral Healthcare Association (AMBHA), and a quality control manager from Federal Express.
"The revolution is over, the coup has occurred, and managed care is firmly in command," intoned moderator Ed Howard, J.D., executive vice president of the AHR. He noted that nearly 170 million insured Americans now receive some form of mental health services within managed care plans.
An AHR background report handed out at the briefing observed: "For managed mental health care, the question is the same as for managed care in general: whether the lower costs provided by these plans are the result of better coordinated and more appropriate care, or simply of not providing care that may be needed. Among those most unhappy-not surprisingly-are psychiatrists, psychologists, and other mental health professionals who are suddenly finding their treatment decisions questioned and their fees negotiated down. Managed care plans are demanding focused, time-limited, goal-specific treatment plans-which mental health professionals assert are not always feasible. And research is inconclusive about whether short-term psychotherapy of the sort favored by managed behavioral health care companies is as effective as traditional long-term therapies."
The goal of managed care is "less variance and more standardization," said AMBHA Executive Director Clarke Ross, Ph.D. Although managed mental health care results in the expansion of services, it also results in "the substitution of services," observed Ross. Managed care favors interventions with "documented efficacy over those whose results are less clear," he noted.
Carveouts, in which mental health services are provided separately from other medical services, are a response both to the historical segregation of mental health care and the need for special expertise, said Ross. Many health care plans have turned to carveouts because managing mental health benefits within the same framework as other medical benefits has proven unwieldy and expensive, he said.
Mental health carveouts cover 149 million Americans, of which 90 million are covered by the three largest companies-Magellan Health Services, Value Behavioral Health, and United Behavioral Health, according to the AHR. The 10 largest companies cover 80 percent of all enrollees.
Panelist Gail Robinson, Ph.D., senior manager at the Lewin Group, sketched some of the changes in managed mental health care between 1996 and 1998.
In 1996, for example, more than half the states lacked any type of behavioral health care programs under Medicaid. But by this year, only 11 states lacked provisions for mental health care under Medicaid. Similarly, in 1996 only 14 states had Medicaid programs with provisions specific to acute and long-term care of the mentally ill, while by January 1998, that figure had risen to 24 states.
In 1996 large, comprehensive managed mental health care programs were dominated by private sector contracts, while now the picture is far more mixed, said Robinson.
"Many states rely in part on public contractors," she noted, while "governmental agencies and private sector organizations are forming new relationships."
Consumers, too, have undergone a major shift in their relationship to managed care, Robinson said. Prior to 1996, consumers had little input into systems of care. But by 1997, 23 states had enacted 33 consumer and patient protection laws, including, in a few cases, laws giving consumers the right to sue HMO's for medical malpractice. Permitting such litigation makes the HMO, and not just the individual physician, accountable to the consumer.
Lu Crowder, R.N., manager of Federal Express employee benefits, discussed that company's experience with mental health coverage. Federal Express is often held up as an example of a company with progressive mental health benefits.
The company has a fully integrated mental health benefit, which includes an employee assistance program, said Crowder. There are no annual limits. "We're interested not only in cost but in quality," she said. The company's goal is "the least expensive care that meets [employee's] needs."
A recent employee survey found 90 percent satisfied with the benefits, said Crowder. But only 77 percent of providers were satisfied with the arrangement, she added.
Breakthroughs in psychopharmacology make this "a very exciting time" for progress in treating brain disorders, said panelist Laura Lee Hall, Ph.D., NAMI's deputy director of policy and research. But this is also "a very frustrating time," she added, as millions of Americans suffering from these disorders continue to experience discrimination in the provision of health care. Although many members of NAMI fear managed care, its consolidation offers an opportunity to "reform the disaster that preceded it," she asserted.
Managed mental health care companies have improved but still have a long way to go, said Hall. There is "a considerable gap between what's got to be and what is in the managed care industry."
The new medications "are the cornerstone of improvement" in serious psychiatric disorders, said Hall. The clinical reality is that it is impossible to predict "which of these medications will work best for a particular patient," she noted. "So the only appropriate clinical thing to do is have a doctor and patient work together to identify the most effective medication treatment." At present, there are "significant barriers to accessing the new medications in managed care. Formularies are restricted and limited." This applies to both the public and private sector, she said.
Another major priority is emergency access, according to Hall. Ten percent to 15 percent of psychiatric patients kill themselves, she said. "We need to make sure that in the event of a suicide crisis," people can access emergency care "immediately, no questions asked-just like if you have chest pains," Hall asserted.
Recent efforts to expand Medicare will do little to enhance parity in the provision of mental health services, said Ross. "Medicare has one of the most discriminatory mental health benefits in America," he noted. "Medicare financing policy has to be substantially changed, and only the U.S. Congress can do that."
No representatives of APA or the American Psychological Association sit on the Alliance for Health Reform's Board of Directors, which is chaired by Senator John D. Rockefeller IV (D-W.Va.). The AMA is represented by Reed Tuckson, M.D., the AMA's group vice president for professional standards. Other organizations represented on the AHR board include the American Academy of Family Physicians, Merck & Company Inc., AFL-CIO, American Association of Retired Persons, United Hospital Fund, Children's Defense Fund, and League of Women Voters.