This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Organization & FinancingSAMHSA Managed Care Initiative Training SessionsMarch 1998
Date: March 30, 1998-Parklawn Conference Center, Rockville, Maryland
Title: Public Policy - Public Voices: The National Mental Health Association's Innovative Approach to State Healthcare Reform
Speakers: Sandra J. McElhaney, M.A., Director of Prevention
Summary Ms. McElhaney and Ms. Graham presented information on two innovative programs initiated by the National Mental Health Association (NMHA). The two programs include (1) training opportunities for state advocacy coalitions and (2) methods of documenting the role of prevention in managed behavioral healthcare. Before beginning the session, Ms. McElhaney provided a brief overview of the history and described the mission of the NMHA. The NMHA, through its national office and more than 300 affiliates nationwide, is dedicated to improving the mental health of all individuals and overcoming mental illness. Founded in 1909 by Clifford W. Beers, a former psychiatric patient, NMHA is the nation's only citizen volunteer advocacy organization dedicated to addressing all aspects of mental health and mental illness.
Mary Graham
For almost two years the NMHA and its affiliates have worked with coalitions of consumers, families, and advocacy groups in 40 states in training those coalitions to become more effective voices in their states. The training is focused on efforts directed toward state healthcare reform and countering the cost-driven practices adopted by states to save money in the delivery of behavioral healthcare services. Specific NMHA program goals include the following:
NMHA's training program technical assistance programs vary from state to state, depending on local needs and knowledge, but currently include many of the following topics.
Ms. Graham then focused on problems with Medicaid and managed care associated with behavioral services commonly shared by most states. They include the following:
NMHA has found that the formation and advancement of advocacy coalitions difficult for a number of reasons. Added to the diversity of behavioral health needs found in 50 different states, each region or county within a state usually offers different benefits and, most times, each is at a different stage of the procurement process. The issue of "carve-out" versus "carve-in" also has produced divided opinions. (To ensure access and preservation of mental health, NMHA currently endorses the carve-out of both mental health and substance abuse services, until systems are firmly established.) In addition, coalition strategies vary, depending upon: (1) if providers or "for-profit" interests run the program; (2) the different levels of financial risk-do providers assume the risk; (3) if information systems are in place to manage the data; and (4) the ultimate decision maker-the mental health or other state departments. Also, the mix of different services for different populations within each state vary significantly, raising a number of questions such as: Where are children's services included and excluded? Is substance abuse covered? Are both inpatient and out-patient services covered? Are wraparound services provided? And finally, the questions of local politics can create barriers. For example, how much of an issue in the state is mental health? How much funding is available? Are legislatures willing to meet with advocates? Are the advocates working well together? All these issues influence the amount of progress that can be made. In spite of the inherent difficulties, NMHA coalition training can list many program successes. Coalitions have been established in nine states that did not have them previously (CO, FL, IL, LA, MO, ND, OH, TX, and WV). The coalition in California achieved a carve-out of mental health services, a reduction in financial risk, and the elimination of the preauthorization requirement for the use of antipsychotic medications, as well as adding a number of antipsychotics to the state formulary. Louisiana's coalition drafted position papers, testified before the state legislature, and obtained increased funding for Community Mental Health Centers (CMHCs). The state currently is focused on a juvenile justice campaign. In Maryland, coalition participants obtained positions on many different Mental Hygiene Administration committees, such as Fiscal, Clinical, and Management of Information Systems (MIS). Based on such active participation, they achieved a carve-out contract for mental health services. The current concern is fighting capitation. Future plans for state healthcare reform training include:
To date, the State Healthcare Reform Training Program has completed approximately 50 training sessions, and has plans for 20 more in 1998.
Sandra J. McElhaney, M.A.
Ms. McElhaney acknowledged the funding provided by the Center for Substance Abuse Prevention (CSAP) and the Substance Abuse and Mental Health Services Administration (SAMHSA) that made this initiative in prevention and managed care possible. She then explained the process that was used to develop the document. As an organization, NMHA values the entire mental health continuum, which includes prevention, treatment, and maintenance, for both families and consumers. Preventive aspects, unfortunately, have not yet emerged as an issue area within the community and state-based coalitions, although it is an important component of that continuum. Perhaps, this is due to the fact that, historically, prevention has been associated mainly with preventing medical diseases and physical injuries. New science-based evidence, however, now suggests that preventive psychosocial interventions also can reduce the risks for mental health problems and drug and alcohol abuse, as well. In an effort to bring prevention into the mix of mental health issues, staff members at NMHA, SAMHSA, and CSAP, along with selected experts representing a range of constituencies, collaborated in an effort to determine what role prevention should play in managed care. Still a "work-in-progress," the coalition hopes the resulting document will provide the foundation for advancing the concept of incorporating preventive services for behavioral problems into primary care and include issues of parity into the area of prevention. This document also is to serve as a resource for all purchasers of managed care, be it for commercial business, nonprofit, or governmental agencies. The overarching values that serve as a basis for this approach and must be reinforced by purchasers include the following:
The reasons for providing preventive services are simple, yet can be of significant impact. They include: (1) The costs of not providing prevention are huge. Of the 10 major causes of mortality in the U.S., seven are directly related to external factors involving individual behavior as exemplified by the use of tobacco, alcohol, fire arms, or motor vehicles, as well as specific sexual behavior, and dietary/activity patterns, and the illicit use of drugs. The effect of mood, especially depression, on an individual's use of tobacco, drugs, alcohol, and fire arms is compelling. Even those with high depressive symptom levels, but who have not yet developed major depression, are much less likely to quit smoking or are much more likely to use a variety of mood-altering drugs. Similarly, of the 10 major causes of disability worldwide, five are mental health and substance abuse problems, with the number one cause being depression. (2) Prevention can save costs. Long-term health care costs could be reduced and increases slowed through the provision of preventive services. Short- and long-term cost effectiveness is a field which needs further evaluation. Preventive services can have short-term cost effectiveness for business, such as increased employee productivity, decreased absenteeism, fewer workplace accidents, fewer worksite drug and alcohol problems, increased employee satisfaction with healthcare benefits, less turnover, fewer retraining costs, and a reduction in utilization rates and secondary cost consequences. Additional potential savings attributable to behavioral preventive programs include a decreased demand for mental health treatment services, and for primary care services, such as physician visits for physical complaints, reassurance, and treatment of related physical illnesses. (3) Finally, providing preventive services may be proven to be the "right thing to do" for the people being served. The NMHA believes that the only way to ensure the incorporation of preventive services into a managed care contract is to have the purchasers attribute a high value to prevention, deserving immediacy and support. The NMHA concept of prevention is based on Gorden's (1983) model used by the Institute of Medicine (IOM) framework in 1993 to include three types of preventive interventions: (1) Universal-targeted to the general public, not identified on the basis of individual risk; (2) Selective-targeted to a subgroup individuals with a higher-than-average risk of developing disorders; and (3) Indicated-targeted to high-risk individuals, identified as having minimal, yet detectable, signs or symptoms foreshadowing disorders, or biological markers indicating predisposition for disorder, but who do not meet diagnostic levels at the current time. Based on this background information, Ms. McElhaney presented the risk and evidence-based framework for maintaining and measuring preventive services in managed care. This framework is presented for the purpose of consideration by appropriate individuals and constituencies and includes the following premises.
This framework presupposes that the healthcare organization has the interest and capacity to carry out and evaluate these tasks. A social marketing approach will be needed to convince purchasers that preventive services and this framework for ensuring quality and effectiveness should be an inherent part of their contracts with healthcare organizations. Purchasers will need to be convinced that prevention programs have validity, appeal to customers, quantifiable performance measures, the potential to be cost effective, and a universality by payer-i.e., apply to both public and private sectors. At this time the NMHA looks forward to public and professional feedback. They plan to present this to other mental health and substance abuse professionals, as well as other key decision-makers in the coming months.
Question/Comment and Answer Session
Training Issues 17: Can you give us an example of states in which you have been successful? 1: Yes, California. We had some antipsychotics added back to the formulary. This is particularly important for schizophrenia, where each schizophrenic break actually causes brain damage, so that the ability to recovery is not simply postponed, but impaired. 17: How many people were involved in the coalition in CA? 1: There were about 35 people, including consumers, family members, providers, and other disability advocates. 17: When you advise states and look at state contracts do you look at how they handle Early Periodic Screening Diagnosis and Treatment (EPSDT)? 1: Yes, actually that is one of the topics we are thinking of adding in terms of juvenile justice. It's not yet universal in appeal, nor has it been implemented well in the states where it is of some interest. That is why we go back to states several times. The first time we concentrate on three or four action plans. When we return we try for three or four more. EPSDT hasn't been selected as an action area yet. Current areas of interest are consumer rights, formulary restriction, children's health insurance programs, and outcome measures. 17: I heard that in Montana, community mental health programs are having trouble being paid. Do you have any information on that? 1: We plan to go to Montana in May. Since I haven't been there yet, I don't have any information. It sounds like the situation in Tennessee, where the state was so displeased with its managed care organization (MCO) that it withheld 10 percent of their payment. The MCO, in turn, withheld 10 percent of the payment to the providers. One of the key financial issues we talk about is the assumption of financial risk, the amount of stop loss insurance necessary, and financial protection when funds run out. 17: Can you clarify the way you are using the term "carve-out?" You make references with regard to Maryland-the carve out they achieved-and subsequently talk about efforts to avoid capitation. I'm not clear how those two terms fit together. 1: Carve-out versus carve-in refers to whether the mental health and substance abuse services are contracted for separately. Capitation can occur with either a carve-in or a carve-out. Capitation is when a dollar amount per member (covered enrollee) per month (or other unit of time) is established to cover the cost of all health care services delivered. 17: I understand the issue of where the level of risk is handled, but what would constitute a carve-out without assumption of risk? What are you carving out? 1: You're having a separate entity manage the mental health benefit, but they are still paid on a fee-for-service basis. 17: So in a sense there still is financial integration? 1: No, there are still separate pots of money. It's just an issue of who is at risk if the care is more expensive than predicted. The issue we are seeing is something of a hybrid called "shared" or "partial" risk. For example, if the payment is eight dollars per person for services and it costs 10 dollars, two dollars is lost; but if it costs 11, the state will subsidize the one dollar. We're seeing this arrangement more and more. We'd like to see no risk at all for a while, as I don't think there's sufficient data yet for anyone to be making accurate cost projections. MCOs are now beginning to pass the risk down to providers, who do not have appropriate information systems or a history of analyzing the data. It is particularly difficult in carve-ins where, in some states, we see the mental health provider acting as the gatekeeper to primary medical care. It is a lot to expect a mental health clinician to estimate how much referral they will do to general health care. For this and other similar reasons, our advice to coalitions is to slow down the entire process. Q: State legislatures, by and large, are monitoring MCOs and establishing performance requirements. Are you tracking developments in states? That is where the action is. 1: In terms of the Medicaid program and how it is operating, we really do need to be aware of what is happening at the state level. Although we do try to keep abreast of the private sector-focused legislation, a much bigger issue for us is the public sector Medicaid. 17: I would like more information about Maryland. All I know is that many providers are up in arms about the proposed changes and feel they will be destructive to mental health services. 1: [In fact they already are.] All psychotherapists received letters stating the new capitation fees of $60/hour. Where there is an excess of clinicians in the market, as is the case in Maryland, the MCO can do anything they want because there are enough professionals to provide the services. Keep in mind there are several levels of capitation. On the top level, the state can capitate the MCO at a payment of $10/patient. The MCO can then turn to the provider/group practice, at the second level, and pay only $3/patient. At each level of financial risk, a certain dollar amount is taken off the top and the total amount of funds for services is reduced. More information/data is required to determine if the capitation rate is sufficient, and a large segment of the population (i.e., large sample size) is necessary to predict accurately. There is insufficient data at this point to predict. 17: Things also are happening at the county level (i.e., Montgomery County). For example, County Executives also have sent out letters to psychotherapists, expressing their expectations of "humane" treatment, suggesting that they cannot expect to apply their normal, private fee structure to public patients. 1: Let me make it clear that we are not against managed care, nor against profit. We simply want the profit to be reasonable and we want excess to be reinvested in the delivery of services. One of the positives of capitation is that, with the capitation of providers, the MCO has no need to micromanage, as they know the exact amount the services will cost. It has protected, to some extent, the relationship the consumer has with the provider and reduced paperwork. But down the road we may change our position. 18: How much of "medical necessity" is treatment determined? 2: Generally, it varies from state to state. So, how the coalitions handle that issue has to be tailored for each state. 19: From my observations in MCO, it seems, with all the focus on treatments, the concept of prevention is getting lost. 3: That is one of the reasons we have the NMHA program in prevention. 20: Early in your presentation, you discussed problems that tend to divide advocacy groups. Are there common issues where advocacy groups split and what are you doing when this occurs? 4: The common split-opinion issues tend to be parity-whether it should be for all mental health problems or specific diagnoses; self-determination issues; parents versus consumers; and general "turf" battles. We encourage and facilitate ongoing dialogue; once you get people talking there is always greater opportunity for reaching an agreement. Prevention Issues 21: Am I to understand that you believe preventive interventions can keep people free of, for example, depression for their entire life? 5: Yes, prevention of initial onset. 3: I don't believe that will happen. Perhaps you can delay it by one year or five years or into adulthood, but it will never be completely prevented. C: Also, if you are targeting a particular age group you would actually be targeting a segment of the life span. It might be delayed, from adolescence into adulthood, but one would never be followed that long to totally prevent it. 6: I definitely appreciate your feedback; it will be incorporated into the final document. 22: When you mention physical illness, does that include physical disabilities? There is a great deal of interest among our therapists in the psychosocial aspects of physical disabilities. For example, many of our hand therapists are seeing alcoholism in their patients who are on disability and don't return to work. Also, what is your plan for this document? 7: Although not fully developed, our basic plan is to take this framework to managed care companies, purchasers, major constituency groups, and Federal agencies and members of Congress. We also envision this to be incorporated into the state training programs. It also plays into another process called the Santa Fe Summit. The American College of Mental Health Administrators (ACMHA) are interested in the development of outcome measures in managed care. They, in fact, asked us to initiate the process, and this framework will be presented at their meeting in Santa Fe, in April 1998. 23: If a MCOs identifies a patient at risk for mental health disorder, can't that lead to discrimination? 8: We have a number of specific values that speak directly to that. It shouldn't happen. There are number of controls in place to assure that it doesn't-for example, criteria for disenrolling participants that are written into the contract and the the Centers for Medicare and Medicaid Services (CMS) rules for eligibility and enrollment. In addition, the NMHA is trying to eliminate existing loopholes to ensure that criteria are used to protect individuals. 17: What is the strength of the evidence concerning interventions? What are the indicators that cause us to suspect that someone may be more susceptible? This is not an easy question in terms of non-mental health disorders, yet alone mental health issues. It's not clear to me that there is strong, explicit evidence that intervention taken by the MCO is valid. Look at the arguments over screening for breast and prostate cancers-the cost of the initial screening versus the overall value to a population and cost savings at the other end. Where are your numbers? If you go to a MCO audience or purchasers you must have numbers. 9: I can provide you with the background documentation. There really are a number of preventive interventions that have been proven to be effective. The IOM report identified a number. The portfolio at National Institute of Mental Health (NIMH) also has a number of them. They are not cheap. The cost of providing them may be substantial and they do involve cost offsets. For example, in offering a parenting course for new mothers, the cost savings may be found in welfare savings and less child abuse. C: The Center for Mental Health Services (CMHS) has a partnership with CSAP that is looking at that exact question-is the evidence science-based? CMHS will publish a document that provides a listing of interventions that a MCO could consider covering (i.e., paying for) that are based on the literature and, in the short-term, cost effective; and some that are cost-effective in the long-term. One, for example, would be providing psychological intervention prior to surgery, which has been proven to be effective in shortening hospital stays and accelerating the healing process. 17: I think there is some confusion about how the term "prevention" is used. I think there is a difference between preventing a first onset with early identification (primary prevention) and early intervention (secondary prevention). Early intervention is quite well documented, and I think that is where there is some solid evidence. If you treat the symptoms of depression early, that is documented, clinical depression, the symptoms generally become less intense and the episodes are diminished over time. I think you must be a little careful when you talk about preventing first onset-that's a lot muddier! You must make that issue very clear. There is some evidence, however, that when you intervene appropriately, with the working population, people do get back to work. That is a very big issue for industry, in terms of the cost of short- and long-term disability issues. 10: There are some promising programs out there. You speak to another important issue, which is the blurring of the line between prevention and early intervention. NMHA is going through an exercise that will smudge the line even more. Another high-risk population is children of depressed mothers. There is some good evidence that interventions with that population can be effective. 3: Group Health of Puget Sound has published extensively on these issues. That is one of the reasons why the Bureau of Primary Health Care is so interested in the integration of mental health with primary health care. We have a new uniform data system in the Bureau, which has enabled us to extract interesting data for analyses. For example, the number one and number two diagnoses are clinical depression-these are in primary health care settings. Primarily, these are young women with young families, most single mothers. These data document the widespread problem that is not being addressed. Group Health's data shows that approximately 70 percent of the complaints that come through primary care have a psychosocial basis. Much of his publishing has documented the efficacy of the integration of mental health services with primary care. 17: There are two points I want to make. One is the importance of prevention education and outreach. The MCO I used to work for dedicated resources to these issues. Also in RFPs, states and counties often ask for plans in these areas. I wonder, as you pursue this, have you had an opportunity to talk to some of the MCOs and ask what resources they have dedicated to this? The other issue is disease management. This is a concept similar to prevention. From an industry perspective I wonder what are your thoughts on that? 1: In terms of talking to the various organizations, when we brought people together we did have representatives from managed care. They shared information on what programs they were involved with, and there definitely is more going on in substance abuse than mental health. We haven't seen any activity in prevention in the public sector contracts. We're hoping they will include this framework as they move forward with a their next set of standards. In terms of your second question, disease management is not an area where I have seen any interest. 3: Like anything else, "disease management" is anything but new. If you think of the resources for preventive intervention as being self, family, friends, community, and (lastly) professionals, much of the concept of disease management comes from the "old school" of self-care. Not to be confused with "demand management," which is more of a traditional prevention; disease management is having the disease or disorder. Two classic models are hypertension and diabetes (or any chronic condition) where you learn how to take care of that condition without constantly running to primary care or specialty providers. It's how you can maintain your own well-being and quality of life through self-care and going to provider only when it is necessary. It's been used in the mental health field in dealing with chronic depression and schizophrenia. There is a distinction between disease management and demand management-although, because the industry tends not to recognize the term "prevention," they use the term "demand management." |
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