The Provision of Mental Health Services in Managed Care Organizations

Entry Into Specialty Treatment

Previous studies have documented the overall use of specialty mental health care (Regier et al., 1993; Kessler et al., 1999) and examined the effects of various managed care approaches on behavioral health services. (See review articles by Mechanic, Schlesinger, & McAlpine, 1995; Grazier & Eselius, 1999; Sturm, 1999.) However, no national estimates of specialty mental health treatment entry arrangements in commercial managed care plans have been documented. This chapter reports key findings regarding referral and prior authorization procedures for enrollees in managed care products.

Facilitating entry into mental health care is important, since two-thirds of people with mental disorders do not obtain treatment (Regier et al., 1993). Possible reasons for this unmet need include stigma, lack of recognition of mental disorders by both individuals and providers, discriminatory and inadequate insurance benefits, lack of awareness that effective treatments exist, added barriers for subgroups such as racial and ethnic minorities, and confidentiality concerns (DHHS, 1999).

MCOs use a variety of managed care techniques to structure access to specialty mental health services. MCOs may allow enrollees to self-refer to specialty mental health care by calling specialty providers directly for an appointment, have telephone referral centers, or require enrollees to obtain referrals from a primary care physician (PCP) or an employee assistance program (EAP). Furthermore, prior authorization or precertification may be required for treatment to be covered.

Referral Process

Direct Self-Referral and Phone Center Referral Overall, 90% of products allow direct self-referral or require enrollees to call a designated phone number for referral (Figure VI.1). Enrollees' opportunity to self-refer or access specialty mental health treatment via a phone center is significantly more likely in PPO products (97%) than in HMO products (91%), although the large majority of all product types have one of these features. A greater proportion of products with specialty contracts (95%) than products with comprehensive contracts (91%) or internal arrangements (88%) report these approaches.

Primary Care and EAP Gatekeeping Mechanisms

Although primary care gatekeeping was a hallmark of HMOs earlier in the evolution of managed care, we found that only about 8% of products overall and 11% of HMO products require enrollees to obtain a referral from a PCP in order to access specialty mental health treatment (Figure VI.2). Another 2% of all products required EAP referral for access to specialty mental health services. HMO products are significantly more likely than PPOs to report the need for a referral from a PCP or an EAP. No significant differences were found by contracting arrangement.

Prior Authorization Requirements

Regardless of the referral process, prior authorization or precertification may be required for different levels of care. This may involve providers, rather than patients, needing to seek authorization for services before initiating them. Prior authorization may include a range of procedures, from calling a phone center for essentially automatic authorization of outpatient care to undergoing a clinical assessment and triage process prior to accessing care.

The study asked about four levels of mental health care: inpatient hospital, non-hospital residential, intensive outpatient (including day treatment), and outpatient counseling. Prior authorization for inpatient hospital care is virtually universal, regardless of product type (Table VI.1), while for most other levels of care, PPOs are significantly less likely to require prior authorization. For instance, among products that cover outpatient counseling, 90% of HMOs require prior authorization, compared with 74% of point-of-service (POS) products and 40% of PPOs. Requirements for prior authorization also differ by contracting arrangement. Products with specialty contracts are much more likely to require prior authorization than comprehensive contract or internal products, for all settings except inpatient hospital care.

Availability of 24-Hour Crisis Services

Entry into mental health care may be precipitated by (or ongoing treatment marked by) a sudden crisis. The vast majority of products offer emergency room (ER) (96%) and telephone triage (82%) services (Figure VI. 3). A smaller number of products, 58%, report having in-person crisis services available. HMO products were significantly more likely to offer phone triage/referral and in-person services compared with PPOs.

Discussion

The large majority of products feature either direct self-referral or referral through a phone center. This was true for all product types and contracting arrangements. While the HMO model often is associated anecdotally with primary care gatekeeping, this survey found that this approach was infrequent for mental health, probably due to the high rate of specialty contracting among HMOs. Required EAP referral also was rare. Prior authorization is usually required for all levels of care but is most prevalent among HMO and specialty contract products.

For some enrollees, the possibility of referral to specialty mental health providers without primary care or EAP gatekeeping will be experienced as freedom from constraints or privacy concerns and may increase the likelihood of seeking needed care. As one managed behavioral health care organization executive said, "There are already too many barriers preventing people from seeking mental health treatment. The best thing to do both clinically and economically is to remove the barriers that limit access to care." However, we do not know how direct self-referral differs from phone center referral from the enrollee point of view. Furthermore, some may benefit from the triage that phone centers or primary care gatekeepers can provide. One industry expert reported: "When someone calls the phone center number for a mental health referral, it is virtually guaranteed that they will get a referral for care. The only question is what type of treatment. The goal is to connect the person with appropriate care, not to deny care."

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