Managing Managed Care Quality Improvement in Behavioral Health (1997) / Chapter Skim
Currently Skimming:
APPENDIX C
APPENDIX C
Pages 312-335
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 312... ...
The current literature on mental illness treatment and outcomes in managed care is limited in scope and depth, although it is expanding (Mechanic et al., 1995; Wells et al., 1995~. This suggests that much more needs to be known, but provides little insight into the relative importance of different areas of mental health outcomes research and evaluation.
|
From page 313... ...
Among an estimated 185.7 million people with private insurance in 1994,106.6 million were enrolled in plans that offered some form of managed behavioral health care (Iglehart, 1996~. One difference, however, is that the tradition of HMO and indemnity insurance coverage for mental illnesses has not been com' parable to the coverage for somatic health problems.
|
From page 314... ...
Congress. Parity legislation can be expected to shift more of the cost burden for the treatment of severe and disabling mental illness from the public sector to the private health insurance system.
|
From page 315... ...
Structure and Access to Care Choice of Practitioner In concept, indemnity insurance has made it possible to go to any practitioner in the community. This is largely true for well~insured, middle~class Ameri' cans.
|
From page 316... ...
In each community there are limits on the availability of health services, but additional limits that are not present under indemnity insurance plans are likely to be imposed by managed care plans. Even though managed care plans control the availability of physician services, they provide 24-hour access and have financial incentives to provide accessible urgent care during ok hours instead of having enrollees go to hospital emergency rooms (Gold et al., 1995a)
|
From page 317... ...
In McFarland's (1994) review of previous research on HMO services provided for mental illness, he found a "pattern in which HMO members are as likely as or more likely than non'HMO members to visit a mental health provider but tend to have fewer contacts with that provider after the initial visit." The net effect of lower access barriers in managed care should be greater accessibility of services for those with a need for care.
|
From page 318... ...
However, the Massachusetts Medicaid managed behavioral health care carve-out appears to have led to higher rates of specialty care, possibly associated with higher rates of detection and referral (Stroup and Dorwart, 1995~. Since there are complex incentives arrangements affecting care-seeking and mental illness recognition, it is uncertain which direction a hypothesis should be stated; however, the following hypothesis is provided:
|
From page 319... ...
Under the indemnity insurance system, the incentive is to continue to treat mental illness until the coverage limits are reached or the patient decides that no more treatment is desired. Under the managed behavioral health care system, there is active utilization review to assess the need for continuing services in inpatient and outpatient settings.
|
From page 320... ...
As a result, it would be expected that: Hypothesis 2C: The duration of treatment episodes under the managed care system will be shorter than the duration of treatment episodes under the indemnity insurance system. Prescription Patterns There does not appear to be much research on the patterns of medication use for mental illness in managed care settings.
|
From page 321... ...
Under different carve~in and carve' out arrangements, there may be substantial variations in the use of specialty ser' vices among managed care organizations. As a result of these uncertainties, the following hypothesis is suggested: Hypothesis 2E: Adherence to quality-of-care criteria for the diagnosis and treatment of mental illness will be equal under the managed care and indemnity insurance systems, but it will be greater when mental specialists are providing care.
|
From page 322... ...
The expectations that access to primary medical care is better in managed care organizations than in settings covered by indemnity insurance, plus the MOS find' ings comparing HMO and FFS practice settings, lead to the following hypothesis: Hypothesis 3B: Population-based outcomes will be better in the managed care setting than in settings covered by indemnity insurance; greater access to primary care services and utilization of preventive and screening services will lead to lower levels of unmet need, although more limited access to specialty services in the managed care setting will contribute to poorer outcomes among those treated. Unfortunately, there do not appear to be any studies that can support or re' fute this hypothesis.
|
From page 323... ...
Consideration of the incentives and what is known leads to the following hypothesis: Hypothesis 3C: Patient satisfaction with waiting times, financial arrangements, and out-of-pocket costs will be greater in managed care plans; whereas satisfaction with choice of practitioner and practitioner communication will be greater in settings covered by indemnity insurance. The financial incentives and the success of managed mental health care in reducing hospitalizations suggest that the costs of care should be lower in managed care.
|
From page 324... ...
ROLE OF CONSUMER OUTCOMES RESEARCH The expectations have been very high that research using information on patient outcomes can clarify what is appropriate treatment, for whom, and under what circumstances. Outcomes are broadly conceptualized to include disease or clinical measures, health status (physical, mental, and social functioning)
|
From page 325... ...
Assumptions In an effort to focus on specific priorities, assumptions concerning care for a mental illness and the overall care management process will be made. The first
|
From page 326... ...
These will be discussed more fully as specific priority recommen' cations are made. A third assumption is that research on the care of persons with the greatest needs should be given higher priority, as should research on preventing the worst outcomes of mental illness.
|
From page 327... ...
This low rate of eEective care for a population with a specific health problem may be quite similar to the current situation in the treatment of behavioral health problems. Efficacious treatments are available for most mental illnesses.
|
From page 328... ...
Another reason for focusing research on managed care mechanisms and their impacts on outcomes of care is the increasing difficulty of identifying opportunities to compare managed care with "unmanaged" or settings covered by indemnity insurance without some managed care features. The current research opportunities are evolving toward comparisons of populations that receive care under different managed care mechanisms that may be applied with varying degrees of .
|
From page 329... ...
As the managed behavioral health care system attempts to put together provider panels and teams to care for the full spectrum of mental illness and substance abuse problems, there will be questions regarding what makes a cost-eEective team, when a team approach is needed, and how mental health professionals should be trained in the future to participate in managed care. In many ways very little is known about staking and organizational options and how they contribute to consumer outcomes and costs.
|
From page 330... ...
The product could be a national plan that could serve the very useful role that the NIMH National Plan to Improve Care for Persons with Severe and Persistent Mental Illness did in the early 1990s (NIMH, 1990~. The purpose of the plan would be to focus research resources and researchers on key issues in the rapidly changing system.
|
From page 331... ...
The Managed Behavioral Health Association is developing and testing its report card. This work needs to be accelerated and substantially expanded.
|
From page 332... ...
The goal would be quality improvement, and the products would include report card strategies for ensuring accountability. v Focusing on Mechanisms for Managing Care The focus on research into the impact of mechanisms for managing care on consumer outcomes will require new partnerships between researchers and man' aged care organizations.
|
From page 333... ...
Re' search and demonstration initiatives should target innovative models that break from tradition by testing alternative ways to manage care, provide services, and monitor outcomes. SUMMARY AND CONCLUSIONS The growth of managed behavioral health care is making this one of the most interesting times in U.S.
|
From page 334... ...
1994. Health maintenance organizations and persons with severe mental illness.
|
From page 335... ...
1995. Impact of a managed mental health program on Medicaid recipients with severe mental illness.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.