Organization & Financing
SAMHSA Managed Care Initiative Training Sessions
March 1997
Dates: March 12, 1997--Medical Health Liaison Group, Morning Session, American Federation of State, County, and Municipal Employees, Washington, D.C., and SAMHSA Group, Afternoon Session, Parklawn Conference Center, Rockville, Maryland
Title: Provider Networks in Managed Behavioral Health: Characteristics and Controversies
Speaker: Suzanne Gelber, Ph.D., President, SGR Health, Ltd.
Rapporteur: Cathy Fomous, Ph.D., TASCON, Inc.
Background
In this third workshop in a series sponsored by SAMHSA, Dr. Gelber compared behavioral health care to a cottage industry moving towards an industrial model. She stated that behavioral care began as a fragmented, uncoordinated effort consisting of many different kinds of community-based providers, institutions, and practitioners. The providers accessed different funding sources and usually made no explicit connection with one another; duplication and inefficiency resulted.
The industrialization of behavioral health care brings an attempt to offer standardized and more consistent treatment. Mistakes will be made in this evolutionary process. At the turn of the century during the industrial revolution, groups arose to protect the laborers, and regulations appeared to curb the greedy interests of capitalists. Today there are similar activities to protect the consumer and prohibit bad practices. Within this turbulent environment of change, there is an opportunity for health care professionals, planners, purchasers, and evaluators to move the change in a more progressive and positive direction.
Controversies
Several controversial issues are associated with provider networks in managed behavioral health care. Dr. Gelber provided insight in the following areas:
1. Cost vs. quality-driven care
It should be recognized that the cost drivers have forced the examination of important questions on quality. There are many different perspectives on what constitutes the best value for limited health care dollars. Some purchasers are interested in the long-range goal of quality care; too many simply focus on accounting for dollars, managing funds, or cutting a budget.
2. Types of economic incentives for clients and other stakeholders
The literature on HMOs, which primarily examines Medicaid data and is oriented to clinical care, suggests that capitation influences the time physicians spend with patients and the type of treatment they recommend. It is unknown if capitation affects other kinds of providers in the same way. Dr. Gelber referred to a recent paper by John Iglehart (Health Policy Report: Managed Care and Mental Health, New England Journal of Medicine, 1996 334(2): 131-135) that indicates an overuse of expensive, long-term interventions in behavioral health care and an underuse of community-based programs and alternative models of care. The capitation system poses a threat to underserve the patient. Theoretically, however, the outcome of economic incentives is to keep people out of hospitals through the use of preventive and early intervention services.
3. Extent of suitable cultural diversity and professional diversity
Provider networks are not diverse enough. The labor pool in behavioral health and the leadership of provider networks do not reflect the cultural diversity of the client population. Nationwide, there are shortages of culturally diverse therapy programs as well as therapists who speak more than one language. Educational opportunities and recruitment will play important roles in meeting the demand for more choice.
4. Degree of inclusion and support for consumers and community-based programs
In the past, substance abuse and consumer groups had a small voice. The participation of these groups is important in order to learn what treatments, interventions, or therapies work best.
5. Impact of assumption of clinical and financial risk
Economic incentives may improve efficiency but not necessarily effectiveness. A better mechanism is needed to collect adverse data and use these data in a constructive manner.
6. Impact of network exclusion on providers
Networks grew too big and unmanageable, some with over 32,000 physicians. If a network is too large, it is difficult to assure quality; if it is too small, comprehensive services cannot be offered. The trend is toward smaller, tiered networks. To reduce size, tiered managed care companies exclude certain programs or classes of providers. Community-based services and professions with an oversupply are generally the first cut. Unfortunately, the services for the most vulnerable are often the first excluded.
7. Ability of payers to monitor network performance preemptively or retrospectively
Purchasers have a right to expect that their dollars are well spent. It is not enough to focus on the policy level. It is also important to examine patient outcome and the interaction between the therapist and the client. The important, yet unresolved, issue is which measures should be applied to study outcome, interaction, or performance.
8. Degree of flexibility and individual customerization of network capabilities for clients, customers, communities
Historically, HMOs have not been flexible due to a mandate to provide short-term, crisis-oriented, acute care. They could not cover significant outpatient benefits because of cost issues. Now, with the public sector entering the market as an HMO purchaser, there is an opportunity for change. Competition for public dollars motivates the client to set some standards. These standards should be reviewed and changed on a continuing basis to reflect the innovations in therapy, medications, and alternative treatments. Flexibility is also affected by the administration of the benefit plan. Some vendors liberally administer a rigid plan; others may rigidly administer a liberal plan.
9. The impact of the "L" relationship: horizontal and vertical integration/specialization and its impact
Provider networks are comprised of vertical and horizontal components that form an "L" relationship. The vertical component includes the services delivery network, which involves inpatient, office, mobile, and home settings. Currently, there are many hospital-led services; there is a need for more community-led services. The horizontal component includes policy and regulations. The policymakers and legislators push for less expensive treatment and creatively blend funding sources. Mental health, child welfare, and substance abuse often rely on five to six different funding sources, which leads to uncoordinated services with little regulation.
Dr. Gelber did not elaborate on the remaining controversies:
10. Extent to which public controls can be exerted over networks
11. Viability vs. profitability for networks
12. Ethical and legal challenges to networks and their performance/practitioner performance
Characteristic Elements
Time restraints shortened the discussion of characteristic elements of provider networks in managed behavioral care. Dr. Gelber regards the following as key elements:
1. Written contracts covering facilities, programs, and practitioners with behavioral health expertise
An integrated system of care does not exist for behavioral health. Contracts are usually very complex, and many state performance standards. Too often, numerous standards render the contract meaningless. Sometimes financial penalties are assessed if the contract terms are not met. Frequently, contracts are superseded by letters of agreement, which are not publicly discoverable as they are considered proprietary or confidential. Due to a lack of expertise, public sector contracts do not offer enough protection for the client or organization. Contracts can be improved by limiting the number of cited standards to 10, focusing on improvement plans, and utilizing the necessary expertise.
2. Written credentialing criteria; written and/or online profiling of providers
Many unanswered questions remain in this arena. Network providers should be studied over time for compliance and adaptability.
3. Usually, a direct telephonic single point-of-access system incorporating triage/risk-of-harm assessment and referral to network providers
The actual adherence to this element varies greatly. Most providers have telephonic access, but some have gatekeepers who respond improperly. The care provider who answers or responds to the call or page also adds to the variation. There is a need to examine the operations in the field, not just the paper reports.
4. Defined access and performance standards that govern most contracts but generally differ for each contract/covered population
Geographic and temporal access standards are important issues. Services must be geographically available to the client, along with knowledge or assistance in using public transportation. Temporal access includes the length of time a client waits for an initial or followup appointment, the availability of 24-hour care and an 800 line, choice of treatment in a group or individual setting, and the presence of professional diversity. Managed care opened the door to more people; it is unethical not to care for them once they are through the door.
5. Increasing emphasis on obtaining appropriate accreditation as an organized system of care as a substitute for some due diligence requirements of payers and consumers
Accreditation adds a layer of administrative cost, and one needs to ask, does it really help? In order to be meaningful, review should be frequent, especially as the clients or providers change.
Dr. Gelber also identified the following as important characteristic elements:
- Explicit agreements to form organized systems of care for covered populations
- Written and/or online protocols/guidelines governing utilization management and contract language reflecting expectations of network practitioners and other members regarding utilization management
- Enrolled population(s) with defined expectations regarding access
- Written rules governing enrollee use of network and non-network providers and economic incentives to use network providers
- Rules regarding network level coverage of non-network care for enrollees (emergencies, out-of-area, subspecialty referrals)
- MIS specific to network utilization that generates reports for payers, regulators
- Written rules regarding network grievances, complaints, and appeals, administrative and clinical
- The continua of care from office-based or home-based to highly intensive inpatient; generally include or may be specific to public sector providers and programs
- Written, network-specific and contract-specific quality management capability, often with dedicated staff and budget
- Unwritten rules regarding network staffing and type of provider ratios and "capacity" to accept new providers; sometimes payer-specific
- Economic and access incentives to favor using network providers
- Evolution of tiered networks over the last 10 years and delegation of utilization management to "core" preferred provider/group practices
- Emphasis on using least intensive, least intrusive levels of providers that can address enrollees' needs and public safety
- Written and unwritten expectations regarding benefit plan interpretation by network clinicians and staff
- Varying degrees of emphasis on and accommodation of consumers, transitions to managed care, special customer requirements, and public sector/public health concerns
- Network leadership varies from clinical to administrative flavor
- Performance expectations of lawyers, consumers, and payers increasingly govern network infrastructure and investment, as do antitrust concerns
- Risk sharing and risk assumption built into most contracts; discounted fee-for-service and Administrative Service Organization (ASO) arrangements increasingly supplanted by risk-sharing and capitation agreements
- Public sector networks often have special transition rules, capacity and diversity requirements, special subsets of providers, and broader coverage of benefits and providers than private sector networks
- Contracts are an instrument of competition and regulation/evaluation of networks
- Networks may focus on many different types of payers--"wholesale," "retail," public or private, some managed care, some direct relationships
- Gatekeeper networks very common, but the definition of gate varies; some HMOs moving to direct access to behavioral health triage/referral
- Network functions are clinical and administrative and include member services, clinical triage and referral, claims/risk capability, provider relations, customer relations, marketing, quality management
- Networks becoming larger and more formally structured as health systems become more complex (joint ventures, mergers, and acquisitions)
- Extension of behavioral health horizontally to include providers of services to disabled persons, persons with special health care needs, children and adolescents, criminal justice/juvenile justice, child welfare clients, persons with mental retardation, special populations, and elderly
- Provider recruitment, retention, credentialing processes vary significantly by network, by payer, by contract, by accreditation agency
- Network structures vary from group/staff HMO to an IPA (Independent Physicians Association) type of HMO, to POS (Plan of Service) to PPO (Preferred Provider Organization); accompanying infrastructure differences and economic requirements
- Increasing emphasis by payers and consumers on flexibility, accountability to both; community accountability least certain
Question and Answer Session I
(National Mental Health Liaison Group Participants)
1.
Q: It seems to me that the measures used for monitoring are based on the medical model, and they have been applied to the behavioral health care model a la HEDIS 3.0. Are they the right measures to apply?
A: There seem to be dual report cards for private and public sectors, and different groups of people advocate different models. The scientific basis in medicine is also controversial. An example is the recent task force that could not reach a decision on mammography. We do need appropriate measures, arrived at in a concerted and consensus-oriented way. The system must be reasonable so the providers and companies managing mental health are not bombarded with requests. There is already considerable overhead, and it is not fair to expect managers to generate customized reports for each of the payers. We have a lot of work to do.
2.
Q: Isn't the market place forcing providers to develop innovations along the continuum of care?
A: Yes, the market place has pushed because of cost issues and forced innovation. This is a healthy thing. There was perhaps too much reliance on certain kinds of standard levels of care. How did this happen? Because that is what payers were paying for. Do providers offer a 28-day program because it is best for the patient? No, because that is what insurance paid for. There were many forces acting in this industry that created one set of therapies, approaches, and levels of care. Now we have a much more diverse set.
3.
Q: I am interested in your comment about how little has changed between clinician and client because the clinician as gatekeeper has changed significantly.
A: I am not sure we can contribute anything, in terms of effectiveness, to managed care. There is more administrative work, perhaps.
4.
Q: Do you see anything in the private or public sector where people are investing in enhancing the skills of therapists?
A: Federal and state agencies, along with professional organizations, have begun to address training needs. But no one has the money to do it all, so it will require a consensus of what people need in terms of training. No one professional association can carry the ball for everyone. I'm not sure that training in managed care that is conducted along strictly professional guidelines really serves the therapist very well. It may result in a curriculum that is not sufficiently broad and comprehensive. I would like to see training sponsored by multiple agencies.
5.
Q: What do the purchasers use as their endpoint--productivity?
A: There is a mixture of motives among purchasers--both good and bad. Some just want to cut benefits; others are more paternalistic, wanting to do good but not necessarily knowing how. I am convinced at the policy level-- for example, Medicaid--that in some instances it is in the hands of people who care only about reducing expenses. They do not care what happens to the vulnerable people whose treatment is reduced. We need to educate the purchasers about the faults of excessive competition; there is too much pressure to cut.
6.
Q: I would like to comment about whether the actual encounter has changed between the therapist and client. The encounter has not changed, but access is a problem--waiting a month for the first appointment, a month between visits, more documentation which shortens the time to see the client, and if it is not an urgent problem, the first visit is in a group setting.
A: There is much more use, especially in the public sector, of the group modality. There is a push toward less expensive therapy, lower level intervention, and less frequent intervention.
7.
Q: If the public sector gets capitation payments from Medicaid, why cannot the the Centers for Medicare and Medicaid Services (CMS) say to the State in the managed care contract--there will be no more than 3 weeks waiting time, etc. Why cannot the Federal Government dictate certain standards for federal dollars in a managed care capitation setting?
A: The Federal Government cannot dictate to the State.
But doesn't the Federal Government dictate that for Federal matching dollars certain services must be covered as the core Medicaid services and beyond that they can be enriched if the State wishes to?
Yes, you can write legislation that requires certain things happen, but it is probably no more effective than writing guidelines. I do not think dictating in this political environment will work, and it is not necessary. The states will take help when it is perceived as useful. In the public sector there are too many standards and no enforcement. How do you guide and influence without spending a fortune on enforcement? And what kind of time does it take to check on people? The multiplicity of standards is impossible even for the regulators.
8.
Q: Even the simplest standard, which may seem like common sense, in a behavioral health care context may not be so simple; for example, NCQA requires family involvement once a year. When the focus is on the individualized nature of interaction, it seems oxymoronic that we establish minimum standards.
A: I disagree, I think you can if people understand the standards are the "floor" and not the "ceiling."
But whenever you establish standards they become the "ceiling."
I think we can agree on minimum standards, but they need to be updated continually, and we need input from the consumer. Also, we cannot make it so expensive to implement the standards that it defeats the purpose.
9.
Q: Is there a lot of controversy in the literature on cost-offset?
A: Yes. For substance abuse, medical care costs triple if the patient goes untreated. It is not as clear in mental health. Many studies are split almost evenly on the issue of cost-offset.
10.
Q: Whether IBM or CHAMPUS is the payer, I think they are starting to question the avenue of approach.
A: Yes, we need to educate the payer for long-term life support. We should treat people who are not so ill using prevention or early intervention.
11.
Q: I have concerns about the values between public and private payers. If it is a public payer, the state should tell managed care--we're paying for this, and here are the values we operate under.
A: It does not work like that; you cannot legislate values. Yes, contracts need to be more thoughtful, and people need help on how that is done. Regulating really does not work because you have to enforce it.
12.
Q: You cannot regulate behavior, but there is a responsibility to say--this is how we will behave. Too often we let payers off the hook by focusing on the outcome when there have been clear guidelines or clear language in the contract.
A: We are in a political environment where is it unpopular to dictate to states what they should do. You can change behavior and attitude, but there is much work to do.
13.
Q: Are there any positive model provider networks?
A: Like restaurants, some are good for a while, and then things change; they wax and wane. You can find examples of well-designed networks within the larger, heterogeneous employers, and that includes state health plans like those of New York and California. Whether they will persist and continue to be successful, I do not know. Everyone has an opinion concerning successful; the consumer's opinion seems to be quite different from the purchaser's. Also, you have to step back and see who is asking the questions, who wants to know.
14.
Q: I think there need to be basic regulation and a way for consumers to challenge the system.
A: No one is using the appeals process. You can have the greatest mechanism in the world, but the rate of appeal is less than one percent. It is not enough to just create a great appeals system. Virtually every managed care organization has an appeals process; some are independent; others contract out the second or third level of appeal to an external entity. The point remains--the number of cases is negligible. It is important to make the appeal process accessible. Information must be in a simple format, with simple directions, and available in languages other than English. We need to do a much better job of educating consumers about their rights and making it easier for them to use the appeals system.
Question and Answer Session II
(SAMHSA Group)
1.
Q: Could you comment on confidentiality?
A: Confidentiality has become a shield for those who do not want change. We need to find a way to collect data without violating confidentiality.
2.
Q: What is the future of alternative programs in traditional networks?
A: In the public sector there is still time to structure networks to include a large array of programs. To compete effectively and remain a part of networks, there will need to be some liability protection. Insurance companies could play a large role in the survival of alternative programs.
3.
Q: If you were given $1 million, where would you start?
A: With information systems because you cannot manage what you do not know about. We need to have systems that collect people's experience with health care, along with the providers' experience.
4.
Q: Can you comment on the extent of cultural and professional diversity?
A: We have a dilemma within the profession. We do not have sufficient cultural, ethnic, gender, age, or socioeconomic diversity. We have not educated sufficient numbers of culturally diverse professionals who can provide services or management. Networks are not held accountable enough for their mix in terms of ethnicity, gender, etc. They fall back on the excuse that there are not enough in the labor pool. It is not enough to educate more people who have the skills to work in the managed care environment: we need to foster a commitment to public service. We need to do a better job of ensuring that the networks become more diverse than they are currently.
5.
Q: Can you comment on the survivability of traditional public mental health and substance abuse care providers? Given what you know about the way networks operate, particularly networks under Medicaid managed care, what do you see as the implications of networks for the way these providers traditionally operate?
A: There are some provisions to grandfather community-based programs into the network. After 12 to 18 months these programs must compete for network membership. I suspect many will not make the cut. No one is tracking if these programs are able to make it into the network as full-fledged members. Community mental health is in big trouble. The community-based providers are threatened with immediate demise. They cannot be assured of referrals, even if they get into a network. In addition, the substance abuse community is split internally. It does not have the resources or expertise, and there are insufficient relationships with the mental health agencies.
6.
Q: What is the role of public dollars? On one hand you can look at it as enabling the substance abuse providers, allowing them to be grandfathered in, and on the other hand, should they be let in the arena with questionable performance?
A: Yes, it is questionable, but it is the only way to go. We have to use public dollars to encourage agencies to work together. We need to help people, at whatever level, to work together.
7.
Q: Managed care is usually based on medical models, and we know that often what works for substance abuse is not a medical model. How do we change that?
A: Go to the purchasers, and teach the purchasers what to ask for. Those with the dollars can shape the way these networks evolve.
8.
Q: Do you think there will be a swing in the pendulum back toward freedom of choice in community services?
A: No, I think it is gone. We had no better control over that system. We had no idea what happened in that system except for the worst-case scenarios.
9.
Q: I understand that Senator Wellstone (D, MN) is trying to introduce a bill to establish parity for substance abuse. What, if any, hopes do you have that federal legislation will impact independent agencies?
A: I believe there is a role for legislation in a broad and symbolic sense, not in an instrumental sense. It is not enough to decree it or write it into law. There must be funding for compliance and a system of retrospective or prospective studies.
10.
Q: Do you think there should be advocation for state laws?
A: I think States are ready to take initiative at some level. Too many managed care companies are talking at both ends. They say they want public sector business and will do anything to get it, and on the other hand, they try to defeat every attempt to make it more accountable.
11.
Q: Most of the big managed care companies and HMOs have been working with big business for a long time. Are there any models that provide accountability and good service?
A: Yes. The private sector effort happened at a much earlier point in the evolution of those networks, when vendors were hungrier for business and somewhat less rigid. They also used primarily "carve-outs," which were much more customized. Most of the big businesses explicitly rejected the HMOs as being too rigid to handle behavioral health. That's what led to the rise of the "carve-out" industry, the large client saying that the HMOs do not serve their people. However, big business did not look at cost shifting because of not wanting to fund it. Vendors did not want to do this either because it also took money they did not have. In addition, cost shifting was not examined because the premise on which most of these programs were built was to shift the cost to the public sector. The program gave people access to benefits and when those benefits ran out, they were explicitly transitioned to the public sector. There is now a large project comparing Medicaid/Medicare and managed behavioral health care, examining data from large employers. So, we will know more in the future.
12.
Q: I have the impression that States contracting with managed care organizations are stating who should provide services, but not much beyond that. Are you advocating that States be more directive about how networks are created and operated?
A: Do not assume that because you have decreed it, it will happen. There should be more focus on process, not structure. The structure only gets you through the first 2 weeks. The States have limited funds for surveillance. I think we need tracer events, certain kinds of evidence, to follow what is working.
|
