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The Provision of Mental Health Services in Managed Care Organizations

SURVEY ON ALCOHOL, DRUG ABUSE AND MENTAL HEALTH SERVICES UNDER MANAGED CARE

EXECUTIVE DIRECTOR SURVEY - SUMMARY

This survey is designed as a telephone survey lasting approximately 30 minutes. To provide an overview of the topics covered, this summary presents the main question and answer categories. During the actual survey, the interviewer often will:

  • Inquire about mental health as well as substance abuse services;
     
  • Ask if responses apply similarly to multiple PRODUCTS (e.g. HMO, PPO, POS) within a managed care organization;
     
  • Provide explanations about terms or abbreviations used in some questions;
     
  • If applicable, allow a respondent to refer the interviewer to a specialty behavior healthcare vendor or provider organization;
     
  • Focus answers specific to the managed care organizations operations in particular SITES (e.g. Boston, Syracuse, Portland, etc.).
     

I. DELIVERY/MANAGEMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

The first series of questions is designed to establish if a managed care organization (MCO):

  • Provides behavioral health services directly, either by administering the network of providers or by employing the providers that enrollees use
     
  • Contracts with a managed behavioral health care vendor, a specialty network or provider organization, or integrated provider group for:
     
    • delivery of services
    • management of services

If the MCO holds any contracts, the next set of question determines the names of vendors and which services are provided. This section of the interview determines the flow of the remaining questions about contract features, benefits, service provision, and quality assurance.

II. CONTRACTING WITH MBHC VENDORS, PROVIDER ORGANIZATIONS, AND INTEGRATED NETWORKS (only asked if MCO holds any contracts)

  1. In your current contract, which of the following functions are provided with regard to substance abuse services?
     
    1. a provider network
    2. claims processing
    3. utilization management
    4. quality improvement
    5. case management
       
  2. In your current contract, for which of the following areas are written performance standards specified in the contract?
     
    1. Claims processing
    2. Patient satisfaction
    3. Staffing/Network
    4. Clinical referral speed
    5. Quality assurance system
    1. HEDIS behavioral health measures
    2. Disenrollment (patient disenrollment)
    3. Complaints and appeals
    4. Administrative reporting
    5. Provider satisfaction
    6. Member Services phone response
     
  3. Do you pay a capitated amount to cover both claims and administrative costs?

    [IF PAYS CAPITATED AMOUNT] If claims cost exceed the capitated amount, how much of the additional costs are [MBHC VENDOR/PO] required to pay, according to the contract?
     
    1. All of the cost
    2. Part of the cost
    3. None of the cost
       
  4. Does the contract specify that you will reduce [MBHC VENDOR/PO] payment if performance standards are not met? (e.g., patient satisfaction, clinical referral speed, etc.)
     
  5. What is the maximum amount that [MBHC VENDOR/PO] could forfeit by failing to meet performance standards?

III. BENEFIT DESIGN

  1. Does the substance abuse treatment covered by your MCO provide for the treatment of both alcohol problems and drug abuse problems, alcohol problems only, or drug abuse problems only?
     
  2. IF BOTH COVERED: Are the benefits your enrollees receive the same for alcohol treatment as for drug abuse treatment?
     
  3. Which of the following substance abuse services are covered?
     
    1. Inpatient or residential detoxification
    2. Inpatient or residential rehabilitation
    3. Intensive outpatient treatment (partial hospital or day treatment)
    4. Outpatient detoxification
    5. Outpatient methadone maintenance
    6. Outpatient rehabilitation (non-methadone)

Lifetime Limits

  1. In the most commonly purchased package, what is the maximum lifetime dollar amount, number of inpatient episodes and/or number of inpatient days specifically for substance abuse services?
     
  2. Is there an overall combined lifetime limit for all medical services, including substance abuse and mental health services?

Annual Limits

  1. In the most commonly purchased package, what is the maximum annual dollar amount and/or number of substance abuse outpatient visits covered per year?

Deductible/Copayments

  1. In the most commonly purchased plan, is there a deductible that must be met before enrollees can access mental health and substance abuse services?
     
  2. In the most commonly purchased package, what is the co-payment or co-insurance rate that enrollees pay for OUTPATIENT VISITS? If cost sharing varies by the number of visits, please indicate the initial level.
     
  3. Within the covered visits, is there any change in the co-pay or co-insurance depending on the number of visits?
     
  4. What is the new co-pay or co-insurance rate once initial visits are used up?
     
  5. Is there an out-of-network option?
     
  6. What is the co-pay or co-insurance for out-of-network mental health and substance abuse outpatient visits?
     
  7. Is a co-pay or out-of-pocket payment ever required for prescription drugs prescribed by in-network providers for substance abuse and/or mental health problems?
     
  8. And is the co-pay or out-of-pocket payment the same for substance abuse and mental health prescriptions?
     
  9. Does this product have an open or closed formulary?
     
  10. [IF CLOSED] What level of coverage do enrollees have for non-formulary drugs?
     
    1. No coverage for the prescription
    2. Reduced coverage or increased co-pay

IV. STAFFING AND PROVIDER PAYMENT

  1. [IF A CONTRACT] Which organization has primary responsibility for recruiting and selecting individual specialty practitioners: your organization or [MBHC VENDOR/PO]?
     
  2. [IF A CONTRACT] Which organization has primary responsibility for setting individual practitioner payment policies: your organization or [MBHC VENDOR/PO]?
     
  3. [IF A CONTRACT] Which organization has primary responsibility for selecting facilities, for example, clinics or rehabilitation centers: your organization or [MBHC VENDOR/PO]?
     
  4. Which of the following factors are used in decisions over hiring or selecting, and retaining providers specializing in mental health or substance abuse care?
     
    1. Direct verification of current licensure
    2. History of liability claims
    3. Profiling of provider utilization rates
    4. Provider's agreement to take panels of predetermined numbers of patients
    5. Need for coverage in the specific geographic areas
       
  5. How many mental health and substance abuse specialty providers deliver services in [SITE]?
     
  6. As a practical matter, is there steerage to a group of your highest quality behavioral health providers?
     
  7. What percentage of physicians are in this core group?
     
  8. What percentage of non-physicians are in this core group?
     
  9. Please tell my by what payment mechanism your vendor pays for each of the following substance abuse services. (Discounted Fee for Service basis, a Per Diem basis, a Per Case or DRG basis, or a capitation arrangement)
     
    1. Inpatient hospital or residential detoxification
    2. Inpatient hospital or residential rehabilitation
    3. Intensive outpatient treatment (partial hospital or day treatment)
    4. Outpatient detoxification
    5. Outpatient methadone maintenance
    6. Outpatient rehabilitation (non-methadone)
       
  10. What percent of your enrollees used any substance abuse services in 1998 in [SITE]?

 

FAX BACK ENROLLMENT INFORMATION

Finally, respondents are sent a short form asking the number of enrollees in each PRODUCT (e.g., HMO, PPO) in the SITE (e.g., Boston, Syracuse, etc.) and are asked to return their responses by fax.

 

 

SURVEY ON ALCOHOL, DRUG ABUSE AND MENTAL HEALTH SERVICES UNDER MANAGED CARE

EXECUTIVE DIRECTOR SURVEY - SUMMARY

This survey is designed as a telephone survey lasting approximately 30 minutes. To provide an overview of the topics covered, this summary presents the main question and answer categories. During the actual survey, the interviewer often will:

  • Inquire about mental health as well as substance abuse services;
     
  • Ask if responses apply similarly to multiple PRODUCTS (e.g. HMO, PPO, POS) within a managed care organization;
     
  • Provide explanations about terms or abbreviations used in some questions;
     
  • If applicable, allow a respondent to refer the interviewer to a specialty behavior healthcare vendor or provider organization;
     
  • Focus answers specific to the managed care organizations operations in particular SITES (e.g. Boston, Syracuse, Portland, etc.).
     

I. PRESCRIPTION DRUGS FOR MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS

  1. First, does [PRODUCT] have an open or closed formulary?
     
  2. [IF CLOSED FORMULARY] Which of the following medication are included in the formulary?

    1. Naltrexone
    2. Buprenorphine
    3. LAAM
    4. Antabuse
    1. Clonidine
    2. Prozac
    3. Wellbutrin
    4. Paxil
     
  3. How are exceptions granted to the closed formulary list?
     
    1. Prescriptions are allowed only by selected providers
    2. Approval by the medical director is required
    3. Approval by clinical quality committee is required
    4. Approval by an appeals committee is required
       
  4. [IF OPEN FORMULARY] is preauthorization required for any mental health or substance abuse medications?
     
  5. Which of the following medications require preauthorization?
    1. Naltrexone
    2. Buprenorphine
    3. LAAM
    4. Antabuse
    1. Clonidine
    2. Clonidine
    3. Prozac
    4. Wellbutrin
    5. Paxil
     

II. SCREENING OF PRIMARY CARE PATIENTS

  1. Are primary care practitioners required to use standard screening questionnaires for detecting alcohol problems among at least some of their patients? (By "standard screening questionnaires," we mean questionnaires such as the Michigan Alcoholism Screening Test or questionnaires on alcohol abuse developed by your MCO.)
     
  2. Are primary care practitioners required to use standard screening questionnaires for detecting drug abuse problems among at least some of their patients? (By "standard screening questionnaires," we mean questionnaires such as the Substance Abuse Subtle Screening Inventory or questionnaires on drug abuse developed by your MCO.)
     
  3. [IF YEST TO SCREENING] Are primary care practitioners required to conduct substance abuse screenings on:
     
    1. All patients on a periodic basis (e.g., annually)?
    2. New patients at first visit?
    3. Patients with specified symptoms or TRIGGER CONDITIONS?
    4. Patients within specified AGE GROUPS?
    5. Patients identified by clinical judgment?
       
  4. [IF YES TO TRIGGER CONDITONS] Which of the following are trigger conditions for substance abuse screening?
     
    1. Pregnancy
    2. Traumatic injuries
    3. Emergency room visits
    4. G.I. or liver symptoms
    1. Smoking
    2. AIDS or HIV
    3. Presence of a mental health disorder
    4. Other (please specify)
     
  5. [IF YES TO AGE GROUPS] Please indicate whether each of the following age groups is screened for substance abuse.
     
    1. Adolescents, 12-17 years old
    2. Young adults, 18-35 years old
    3. Middle-age adults, 36-64 years old
    4. Adults 65 years or older
       
  6. Are primary care practitioners required to use general health screening questionnaires that include questions on mental health and substance abuse problems?
     
  7. Apart from the primary care-based screening we've asked about, does MCO conduct any substance abuse or mental health screenings through telephone or mail surveys?

III. TREATMENT OF MH/SA DISORDERS BY PRIMARY CARE PROVIDERS

  1. Are there written guidelines specifically for primary care treatment of substance abuse disorders?
     
  2. [IF YES] Are these guidelines distributed to the primary care practitioners?
     
  3. Which of the following topics are addressed in these guidelines?
     
    1. Provision of brief interventions
    2. Referral to mutual help resources, such as AA or NA
    3. Prescribing and monitoring medications for alcohol or drug abuse problems
    4. Consulting with specialty abuse practitioners
    5. Criteria for referring out to specialty care
    6. Provision of educational materials to patients
       
  4. Are most primary care practitioners paid on a salaried basis?
     
  5. Do primary care practitioners bear any risk for the cost of mental health and substance abuse services, mental health services only, substance abuse services only, or neither services?

    For which services do they bear risk? (inpatient services only, outpatient services only, inpatient and outpatient services)

    Is that full risk or partial risk?

IV. ENTRY INTO SPECIALTY MH/SA TREATMENT

  1. Can enrollees receive specialty substance abuse treatment by means of direct self-referral to a provider?
     
  2. Which of the following are required in order for enrollees to receive specialty substance abuse care?
     
    1. Get authorization from their primary care practitioner
    2. Get a referral by an employee assistance program
    3. Call a designated phone number (e.g., toll-free) to get an authorized referral
       
  3. For outpatient substance abuse services, when enrollees phone to request a referral, which of the following takes place?
     
    1. Referral is given automatically; no clinical assessment is involved
    2. Clinical assessment is conducted over the phone
    3. Other (please specify)
       
  4. Please indicate how frequently each of the following practitioners speak with patients when patients call the designated number for a substance abuse referral:
     
    1. Psychologist, doctoral level
    2. Masters level clinician (e.g., clinical social worker or clinical nurse specialist)
    3. Registered nurse (RN)
    4. Certified or licensed substance abuse counselor
    5. Administrative staff
       
  5. What crisis services are available to patient 24 hours a day?
     
    1. Phone triage or referral
    2. In-person services operated or contracted the MCO
    3. Emergency room services

V. INITIAL TREATMENT AUTHORIZATION

  1. Which of the following substance abuse services require pre-certification or prior authorization in order to initiate the service? And, what is the typical number of days or visits initially approved?
       
    1. Inpatient or residential detoxification
    2. Inpatient or residential rehabilitation
    3. Intensive outpatient treatment (partial hospital or day treatment)
    4. Outpatient detoxification
    5. Outpatient rehabilitation (non-methadone)
    6. Outpatient methadone maintenance
       
  2. What organization conducts the initial utilization review for mental health care and substance abuse treatment?
       
    1. The managed care organization
    2. A specialty provider organization
    3. A managed behavioral health care vendor
    4. A leased or contracted integrated network
    5. A utilization review vendor
       
  3. How frequently do each of the following practitioners perform the initial utilization review for substance abuse treatment?
       
    1. Psychologist, doctoral level
    2. Masters level clinician (e.g., clinical social worker or clinical nurse specialist)
    3. Registered nurse
    4. Certified or licensed substance abuse counselor
    5. Administrative staff
       
  4. How frequently does each of the following practitioners have the authority to deny services for outpatient substance abuse treatment?
     
    1. Psychologist, doctoral level
    2. Masters level clinician (e.g., clinical social worker or clinical nurse specialist)
    3. Registered nurse
    4. Certified or licensed substance abuse counselor
    5. Administrative staff
       
  5. How frequently do each of the following have the authority to deny services for inpatient or residential substance abuse rehabilitation or mental health care?
     
    1. Psychiatrist or physician specializing in addictions medicine
    2. Other physician
    3. Psychologist, doctoral level
    4. Masters level clinician (e.g., clinical social worker or clinical nurse specialist)
    5. Registered nurse
    6. Certified or licensed substance abuse counselor
    7. Administrative staff
       
  6. What organization reviews appeals when initial requests for treatment are denied?
     
    1. The managed care organization
    2. A managed behavioral health care vendor
    3. A specialty provider organization
    4. A leased or contracted integrated network
    5. A utilization review vendor
    6. An external, independent review organization
       
  7. If there is a dispute regarding the appeal decisions, which organization has the final decision-making authority?
    1. The managed care organization
    2. A managed behavioral health care vendor
    3. A specialty provider organization
    4. A leased or contracted integrated network
    5. A utilization review vendor
    6. An external, independent review organization

VI. PROVISION OF SPECIALTY MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT

  1. Are there formal standards for the maximum waiting time from requests for treatment to the initial appointment for each of the following types of treatment?
     
  2. [IF YES] What is the maximum amount of time specified for:
     
    1. Routine treatment
    2. Urgent treatment
    3. Emergency treatment
       
  3. Is assessment of a mental health or substance abuse disorder typically conducted separately from treatment; that is, by a different practitioner or in a different location?
     
  4. How are assessments usually conducted?
     
    1. In person only
    2. By phone
    3. Both
       
  5. How often are routine substance abuse assessments conducted by each of the following practitioners?
     
    1. Psychiatrist or physician specializing in addictions medicine
    2. Psychologist, doctorial level
    3. Masters level clinician (e.g., clinical social worker or clinical nurse specialist)
    4. Registered nurse
    5. Certified or licensed substance abuse counselor
    6. Administrative staff
       
  6. How frequently does each of the following practitioners provide individual outpatient substance abuse counseling services?
     
    1. Psychiatrist or physician specializing in addictions medicine
    2. Psychologist, doctoral level
    3. Master's level clinician (e.g., clinical social worker, clinical nurse specialist)
    4. Certified or licensed substance abuse counselor
       
  7. How frequently does each of these practitioners provide outpatient substance abuse group counseling services?
     
    1. Psychiatrist or physician specializing in addictions medicine
    2. Psychologist, doctorial level
    3. Master's level clinician (e.g., clinical social worker, clinical nurse specialist)
    4. Certified or licensed substance abuse counselor
       
  8. Are there written practice guidelines for treatment of _______________ and, Who or what organization developed these guidelines?
     
    1. Alcohol dependence
    2. Cocaine dependence
    3. Major depressive disorder
    1. Panic disorder
    2. Schizophrenia
     
  9. For patients dually diagnosed with mental health and substance abuse disorders, are there:
     
    1. Specialized providers or treatment programs?
    2. Specific treatment guidelines?
    3. Special criteria or procedures for treatment authorization?
       
  10. Does the MCO require that outpatient substance abuse follow-up visits occur within a set time limit after discharge from hospital or residential care?
     
  11. What is the time limit for substance abuse follow-up visits?

VII. AUTHORIZATION FOR CONTINUED TREATMENT AND CASE MANAGEMENT

  1. Using concurrent review, how often is care typically evaluated for substance abuse patients who are receiving the following types of care?
     
    1. Inpatient or residential detoxification
    2. Inpatient or residential rehabilitation
    3. Intensive outpatient treatment (partial hospital or day treatment)
    4. Outpatient detoxification
    5. Outpatient rehabilitation (non-methadone)
    6. Outpatient methadone maintenance
       
  2. Is there a case management program?
     
  3. Do case managers typically do each of the following activities:
     
    1. Meet regularly with patients, either in person or on the phone
    2. Help patients access community resources, e.g., housing, vocational rehabilitation
    3. Flex or extend benefits
    4. Help with coordination of services
       
  4. What criteria are used to assign substance abuse patients to case management services?
     
    1. Discharge from an inpatient or residential facility?
    2. Diagnosis?
    3. Functioning level?
    4. Frequent readmissions or high costs?
    5. Request of practitioner?
       
  5. Who typically conducts case management services for substance abuse patients?
     
    1. Psychologist, doctoral level\
    2. Masters level clinician (e.g., clinical social worker or clinical nurse specialist)
    3. Registered nurse
    4. Certified or licensed substance abuse counselor

VIII. QUALITY ASSURANCE AND IMPROVEMENT

  1. Are patient surveys conducted at least annually that ask specifically about satisfaction with mental health and substance abuse services?
     
  2. To whom are the results of patient satisfaction surveys reported?
       
    1. Enrollees
    2. Individual clinicians, regarding their own patients
    3. Individual clinicians, regarding overall results
    4. QA committee at the MCO level
    5. A QA committee associated with an MBHC vendor or specialty provider organization
    6. A QA committee associated with a leased or contracted integrated network
    7. Other external organizations, such as NCQA
        
  3. Are standardized instruments used to assess clinical outcomes for at least some of the patients receiving mental health or substance abuse treatment?
      
  4. Using these standardized instruments, for which patients are clinical outcomes assessed?
      
    1. A general sample of all patients in mental health or substance abuse treatment
    2. Patients in specific diagnostic categories
    3. Patients receiving certain service types or levels of care (e.g., inpatient, day treatment)
        
  5. Who reviews the results of the outcome measures?
      
    1. Individual clinicians, regarding their own patients
    2. Individual clinicians, regarding overall results
    3. A QA committee at the MCO level
    4. A QA committee associated with an MBHC vendor or specialty provider organization
    5. A QA committee associated with a leased or contract network
    6. Other external organizations, such as NCQA
       
  6. Which mental health or substance abuse performance indicators are tracked?
      
    1. HEDIS behavioral health measures
    2. PERMS measures
    3. Other (please specify):
        
  7. Who reviews the results of performance indicator measures?
       
    1. Clinicians
    2. A QA committee at the MCO level
    3. A QA committee associated with a MBHC vendor or specialty provider organization
    4. A QA committee associated with a leased or contracted network
    5. Other external organizations, such as NCQA
        
  8. Is there an MCO-level committee that oversees quality assurance programs for mental health and substance abuse treatment?
      
  9. Who belongs to this committee?
      
    1. Specialty providers in mental health and substance abuse
    2. Primary care practitioners
    3. Enrollees who are behavioral health care consumers or their family members
    4. Other enrollee

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