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Special Report
Preventive Interventions
Under Managed Care: Mental Health
and Substance Abuse Services
Behavioral Health
Services and
Prevention
Programs and services designed to prevent substance abuse
and mental health problems, detect potential problems early
enough for effective action, or both are often referred to as
"preventive behavioral health interventions." In this document, "behavioral"
refers to mental health and the abuse of alcohol, tobacco, and
both licit and illicit drugs. Some have criticized the term "behavioral
health" as too narrow to describe the diverse issues it addresses and the
range of prevention and treatment approaches it encompasses. The term
is now commonly used in the managed care arena, however, and is recognized
within the public health and medical communities as well.
Prevention can take many forms averting
problems altogether; delaying problem
onset; identifying a developing problem
early enough to make intervention more
effective; or decreasing the severity or duration
of a problem or both. Within the fields
of public and behavioral health, prevention
is defined differently. In public health, prevention
is generally categorized as primary
prevention, directed at averting a potential
health problem; secondary prevention,
directed at early detection and, as appropriate,
intervention to delay onset or mitigate
a health problem; or tertiary prevention,
directed at minimizing disability and avoiding
relapse. In practice, prevention technologies
take three general forms in clinical
practice: (1) prevention strategies that are
usually delivered on a one-to-one basis
within the context of traditional medical
care; (2) behavioral prevention strategies,
sometimes referred to as health promotion,
that focus on adopting lifestyles conducive
to health; and (3) environmental prevention
strategies that are undertaken by a community
to safeguard the well-being of all citizens
(Teutsch, 1992).
In its 1994 report, Reducing Risks for
Mental Disorders: Frontiers for Prevention
Intervention Research, the Institute of
Medicine (IOM) proposed a more restrictive
set of definitions related to behavioral health,
correlated with levels of health risk in target
populations (Mrazek & Haggerty, 1994).
These definitions are based upon a classification
proposed more than a decade earlier
(Gordon, 1983). The "continuum of care"
spectrum that encompasses these three categories
of prevention is shown in Figure 1.
The three classifications within the IOM
Model of Prevention are: universal interventions, offered to an
entire population because their benefits
outweigh their cost and risk;
selective interventions, targeted only to
groups at greater risk than the rest of the
population, incurring a moderate cost justified
by the increased risk of illness; and
indicated interventions, provided only to
high-risk individuals and to those persons
who are experiencing early symptoms of a
disorder either to prevent future development
of a health problem or to reduce the
duration or severity of a health problem.
Post-diagnosis preventive interventions
(Mrazek & Haggerty, 1994) as well as mental
health promotion (Mrazek, 1998) are
excluded from this model. Treatment
includes screening and care for existing
problems; maintenance encompasses aftercare
and rehabilitation. Although the IOM
triad has gained considerable acceptance in
the behavioral health care field, a later
report to the National Advisory Mental
Health Council by the National Institute of
Mental Health (NIMH) Ad Hoc Committee
on Prevention Research utilized a broader
definition and scope of prevention research
(NIMH, 1998).
Risk factors and protective factors are also
central to an understanding of prevention
in the mental health and substance abuse
arenas. The presence of risk factors is associated
with an increased potential to develop
a mental health or substance abuse problem.
Protective factors reduce the potential to
develop these problems. An at-risk individual
may benefit from the presence of protective
factors. Current research seeks to
determine how risk factors that cause problems
can be changed through preventive
interventions (Mrazek & Haggerty, 1994) as
well as to identify, maintain, and strengthen
protective factors.
A recent report sponsored by the National
Mental Health Association, Preventing
Mental Health and Substance Abuse in
Managed Care Settings (Mrazek, 1998),
proposed that preventive behavioral health
services in MCOs incorporate the following
elements:
healthy development across the lifespan;
high priority on children and their families;
assessment and delivery of services
based on modifiable risk and protective
factors;
elimination of access barriers to health
care and incorporation of aggressive
service delivery outreach;
screening of enrollees for early identification
of at-risk populations;
use of risk profiles to deliver preventive
interventions that are operationalized,
defined, and evidence-based;
provision of preventive interventions
that include a maintenance component
to enrollees at risk for substance
abuse;
tracking of performance measures
such as program completion rates,
risk reduction, protective factor enhancement,
decreased onset of disease and
disability, resources invested in preventive
services, and cost savings;
consumer involvement in a partnership
with purchasers to determine health
policy and service; and
partnerships and collaboration between
health care service providers and related
community resources.
From the perspective of the Center for
Mental Health Services (CMHS), prevention is
an attractive alternative to the current
system of trying to mend and maintain
those who suffer because their needs
have not been met. The preventive model
also represents a comprehensive and systematic
approach for dealing with individuals
and their environment in a
humane and holistic manner. On the
other hand, the preventive model, despite
a long history, continues to be plagued
by philosophical and intellectual debate
as well as political conflict. Furthermore,
in the present economic context, the
preventive approach also shoulders the
additional burden of having to compete
for scarce financial resources with the
preponderance of its collateral being a
tenuous promise to reduce the incidence
of future problems....Analysis of costs
and benefits can help inform decision
makers about which kind of preventive
intervention should hold the most
promise for yielding benefits.
(CMHS, 1996c, Foreword)
This review has sorted through the scientific
literature to identify the most cost-effective
and productive preventive interventions an
insurer might include without incurring a
financial loss. The current shift to managed
care provides an opportunity for MCOs to
value and provide prevention with the same
weighted value as treatment and rehabilitation.
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