Comprehensive Mental Health Insurance Benefits:
Case Studies
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
Office of Managed Care
V. Key Managed Care Organization (HMO and MBHO) Findings
Characteristics of Study Participants
Leadership plays a significant role in defining the MCOs' approaches to providing care. (Details of individual MCO case studies are in Appendix D.) For example, Harvard Pilgrim's founding members included several psychiatrists who understood the necessity of integrating physical and mental health care. American Psych Systems' (APS's) management facilitated the organization's development of policies and innovative programs that demonstrate its dedication to providing high-quality mental health care.
While the two HMOs began in the 1970s as staff models, both now operate as mixed models with large provider networks. Both provide a continuum of mental health care throughout all of their plan options; offering comprehensive coverage does not require a specific type of delivery model.
To remain competitive, APS has developed its niche by specializing in small to mid-size employer and HMO clients. This MBHO offers its private and public sector customers a range of products including EAPs, managed behavioral health care programs, and administrative services. Behavioral health care programs are the company's fastest growing business segment.
Mental Health Benefits: Design, Services, and Employee Cost-Sharing Requirements
The HMOs and MBHO place a high priority on integrating physical and mental health care services, as well as requiring open communication and coordination of care between mental health specialists and primary care physicians. For example, APS requires mental health providers to contact a patient's primary care physician when medical conditions present may be complicated by medication or other psychiatric treatment.
The MBHO establishes reasonable and affordable employee cost-sharing requirements because it recognizes that high out-of-pocket expenditures often discourage individuals from accessing mental health benefits. The company also encourages employers to provide services under the EAP at no cost to employees because an EAP offers certain insured populations (e.g., blue collar workers) greater access to services.
All three MCOs offer a wide range of services along the mental health continuum of care. They acknowledge that limiting services to inpatient and outpatient care will not produce positive patient outcomes in the long term.
Benefit Management Approaches
The MCOs report that, in contrast to the six employer study participants, the majority of employers do not manage benefits actively. Instead, many prefer to purchase a prebundled set of services. When they do customize plan design, a task more easily accomplished when the purchaser is self-insured and at risk for the benefit, employers rarely place increased restrictions on services, but instead require additional options or levels of coverage.
HMOs have felt the effects of recent trends toward consolidated and nationalized benefits. All three MCOs use regional strategies to provide care. As more employers purchase benefits through national plans, smaller regional vendors will receive a decreasing market share of private sector business. To remain competitive, these vendors may be required to alter their approach to mental health care.
Employers and HMOs are primarily concerned with a behavioral health care organization's ability to maintain a high-quality provider network and to ensure that patient costs will not increase (particularly because mental health is such a small percentage of an HMO's overall budget). APS, however, believes the most effective method for achieving these goals is through use of innovative payment approaches and minimal direct management of providers. As a result, the MBHO can shift resources from quality control and oversight to focus on monitoring treatment retrospectively for quality and satisfaction.
Employee Satisfaction/Performance Data
NCQA HEDIS measures comprise most of the performance data reported by HealthPartners and Harvard Pilgrim. Both use member surveys to measure satisfaction, quality of care, cost of care, and access to services. In addition, they monitor behavioral-health-specific measures including hospital readmission for mental health patients, antidepressant medication management, and mental health, chemical dependency, and prescription drug use and cost.
APS tracks a wide variety of claims, access, treatment, and outcomes measures through an automated information system, enabling the company to conduct historical comparisons, trend analysis, and ongoing quality improvement.
The MBHO also monitors data included in industry standards, such as the HEDIS measures and the American Managed Behavioral Healthcare Association's Performance Measures for Managed Behavioral Healthcare Programs (PERMS). These standardized sets of performance criteria can provide useful information. For example, when it analyzed the PERMS data for 1998, APS identified a need to improve the rate of ambulatory followup care for patients hospitalized with a substance abuse diagnosis.
Specific Examples of Best Practices
Harvard Pilgrim Health Care: Ensuring Care Across Plan Boundaries
The evolution of PPOs has made providers dependent on payments from a variety of insurers. This dynamic has reduced MCOs' ability to require providers to implement particular programs for each MCO's specific covered populations. Harvard Pilgrim has responded to this problem by instituting a depression screening program in which it pays providers for any patient screenings, including those for patients not enrolled in Harvard Pilgrim plans.
HealthPartners: Uniting Primary Care Physicians and Mental Health Consultants
Recognizing that primary care physicians provide the majority of mental health care, HealthPartners has developed a program in which mental health specialists consult with these physicians. As a result, the primary care physicians have a greater mental health support network when diagnosing and treating individuals with a range of psychiatric problems.
American Psych Systems: Developing Strong Relationships with Network Providers
APS has placed a high priority on fostering long-term relationships with its provider networks. After providers pass the company's stringent selection criteria, APS allows them to make the majority of treatment decisions with minimal intervention. The company has also developed a computerized system to expedite any necessary preauthorization and claims payments, enabling providers to focus on patient care.
Challenges Remaining
The burgeoning popularity of larger provider network options has led to a transition away from staff model HMOs. Extensive networks disperse a provider's population among many different MCOs, limiting the influence those vendors have over the provider. As a result, MCOs have more difficulty developing innovative programs for these provider networks than under staff models.
Increasing pressures from employers to reduce health care expenditures may force HMOs to decrease service levels and to eliminate the innovative services currently provided.
As employers transition from regional to national MCOs, smaller vendors are concerned about their ability to accommodate employer needs under a regional design and must convince employers that they can provide higher quality benefits through a regional approach.
MBHOs often act as subcontractors, providing behavioral health services as part of health benefits offered through an HMO. In such situations, the MBHO does not work directly with employers, limiting its ability to collaborate with an employer to understand and customize benefits to a company's specialized needs.
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