The Provision of Mental Health Services in Managed Care Organizations

Treatment Process

The treatment process is multifaceted and is shaped by both administrative and clinical factors. For managed care enrollees who need mental health services, their experiences can be greatly affected by MCO policies and practices. For example, the time an enrollee must wait until a first appointment may influence whether he or she follows through. The kinds of questions asked when an enrollee calls a phone center referral line may hinder or facilitate getting needed care. Because of the potential impact on enrollees, therefore, it is critical to understand the range of MCOs' approaches to policies that influence care for people with mental health problems.

The survey inquired about aspects of the treatment process that MCOs have direct influence over, including policies setting standards for timely first appointments, the types of clinical personnel providing treatment, standards regarding prompt follow-up after discharge from inpatient care, and special services for patients with dual diagnoses of mental health problems and substance abuse. Another area that can affect the specialty mental health treatment process - the use of practice guidelines - is discussed in Chapter VIII as a quality management activity.

Data also were collected regarding utilization management, "a set of techniques used by or on behalf of purchasers of health care benefits to manage mental health costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision" (Institute of Medicine, 1989). These techniques may include mechanisms to control initial access to care (such as the gatekeeping and precertification procedures discussed in Chapter VI), periodic or concurrent review and authorization for treatment, and case management for specific categories of patients. MCOs vary by the type of professionals and organizations used to perform initial review and by who has authority to deny care for outpatient and inpatient treatment. There is also variation in the types of case management programs, the types of professionals working as case managers, and the different functions that case managers perform.

A number of studies have examined the process and effects of utilization management for behavioral health services. (Recent examples include Frank & Brookmeyer, 1995; Howard, 1998; Wickizer & Lessler, 1998; Liu, Sturm, & Cuffel, 2000.) These studies generally suggest that certain strategies do result in a lower quantity of treatment - sometimes directly through denials or approving less treatment than requested, but sometimes through a "sentinel effect" in which the very existence of the utilization management system seems to deter higher use of services. However, this study is the first to describe the prevalence of a variety of treatment process factors within MCOs on a national basis. This chapter presents some key findings on this topic.

Providers of Mental Health Treatment

Mental health practitioners have different training and backgrounds. They include psychiatrists, doctoral-level psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, marriage and family therapists, and master's-level psychologists and counselors. For both individual and group counseling, master's-level clinicians and doctoral-level psychologists were most often reported to "frequently" provide these services. The lower frequency of psychiatrists in both categories may reflect a decreasing role for psychiatrists in the provision of psychotherapy and an increasingly exclusive focus on providing psychopharmacology services.

Standards for Wait Time to Appointments

An important aspect of access to treatment is to provide timely initial appointments once individuals request services. About three-quarters of all products report having formal standards for maximum wait time from request for treatment to initial appointment (Figure VII.1). Continuing treatment in an outpatient setting following discharge from a psychiatric hospitalization is also generally accepted as necessary. Close to half of all products (43%) reported having standards regarding time limits for follow-up mental health visits after discharge from hospital or residential care (Figure VII.2). HMOs and specialty contract products are most likely to have both types of standards (data not shown).

Services for Patients With Both Mental Health and Substance Abuse Problems

A substantial proportion of people with mental health problems also have substance abuse disorders. For patients with mental disorders who are seen in specialty treatment settings, about one-fifth have had a substance abuse disorder within the past six months (Regier et al., 1990). For those persons with co-occurring mental illness and substance abuse, diagnosis and treatment can be especially complex, and integrated treatment approaches are promising, although additional research is needed on their effectiveness (RachBeisel, Scott, & Dixon, 1999; Herman et al., 2000; Primm et al., 2000; Watkins et al., 2001).

We found that about half of all products reported having specialized providers or treatment programs to treat this dually diagnosed population (Figure VII. 3). HMOs were more likely (71%) to have these compared with PPOs (39%) or POS products (35%). Comprehensive contract products were less likely to have specialized providers or treatment programs (data not shown). One-sixth of all products had specific treatment guidelines for the dually diagnosed, and one-quarter had special criteria or procedures for treatment authorization.

Utilization Review Personnel

This study asked about the types of personnel who conduct initial reviews of requests for additional mental health care. Master's-level clinicians were most often reported to "frequently" perform this review, followed by registered nurses. Only 2% of products report that administrative staff perform this function. As it is generally known that physicians rarely perform this first level of review, the study did not ask with what frequency they do so.

If reviewers decide that the treatment requested is inappropriate or unnecessary, often they do not have authority to implement that denial themselves. Psychiatrists are the professionals most often "frequently" granted authority to deny care for both inpatient and outpatient treatment, followed by other physicians and doctoral-level psychologists. In about two-thirds of products, master's-level clinicians and registered nurses are never authorized to deny care for either inpatient or outpatient treatment. HMO products are less likely to authorize nonpsychiatrist physicians, and comprehensive contract products are less likely to authorize psychiatrists.

Organizational Responsibility for Initial Utilization Review and Appeals

Across all products, more than half delegate initial utilization review MBHOs (Figure VII.4). The MCO retains direct responsibility for initial review for roughly one-quarter of all products, and about 11% use a utilization review vendor for this purpose.

When a denial results from this initial review, an enrollee or provider may appeal. External review programs to provide an independent review of an MCO's decision to deny, reduce, or terminate treatment have been proliferating quickly and have been the focus of attention from managed care accrediting organizations (Dallek & Pollitz, 2000). Overall, MCOs usually delegate initial appeals to other organizations; only about one-third decide initial appeals themselves (Figure VII.4). Among products with specialty contracts, over half report that MBHOs review initial appeals. For products with comprehensive contracts and internal products, more than half delegate this responsibility to utilization review vendors or other external organizations, including independent review organizations (data not shown).

While products typically allow an external vendor or MBHO to rule on initial appeals of the denial of care, 70% of products retain the responsibility for final appeals decisions. There is little variation by product type, although there is variation for products with different contractual arrangements. Products with specialty contracts are most likely to report that the MCO is the organization responsible for the final appeals decision.

Mental Health Case Management Programs

Case management for persons with mental disorders is common. Overall, 87% of products report having a case management program (Figure VII.5). Coordination of services is the most commonly provided case management activity (85% of all products), followed by helping patients to access community resources (76%), flexing or extending client benefits (62%), and finally, meeting regularly with clients in person or over the phone (46%) (Figure VII. 6). Across all products, master's-level clinicians are "typically" used more often than doctoral-level psychologists or registered nurses to provide case management services.

Discussion

The study found that MCOs implement a number of measures to influence aspects of the treatment process, including standards for maximum time to first appointment, timely follow-up after inpatient discharge, and special services for patients with co-occurring mental and substance abuse disorders. Utilization review responsibilities vary considerably depending on the level of review and appeals. In terms of issuing denials of care, psychiatrists and other physicians are far more likely to carry out these functions than other professionals. Organizationally, the higher the level of review and appeal, the more common it is for responsibility to be found with the MCO rather than delegated to external organizations. Regarding treatment provision, master's-level clinicians and doctoral-level psychologists "frequently" provide treatment more often than psychiatrists.

The degree of control exerted over the treatment process may be positive in some cases - for instance, in ensuring that enrollees have timely access to care. On the other hand, some providers and patients may find tight utilization review systems to be an obstacle rather than a useful assurance of appropriate care. However, it is clear that the range of treatment process factors can have potentially important effects. An industry expert pointed out: "In many ways, individual providers cannot control how patients are treated. You have to consider the effects of utilization management, benefits, payment mechanisms, and other factors in the overall system." While an organization-level survey such as this study cannot describe what happens in the actual clinical encounter, the results provide a picture of the degree to which MCOs attempt to influence important aspects of the treatment process.

Previous | Table of Contents | Next