The Provision of Mental Health Services in Managed Care Organizations

Conclusion

The study has reported on a nationally representative survey of MCOs and described in detail differences in the provision of services by product type and contracting arrangement. To understand the impact of managed behavioral health care on patients, it is important to understand the structure and rules under which services are provided.

The major conclusion from this study is that there is diversity in the mental health services that MCOs provide. MCOs must decide whether to carve out to a specialty vendor or to provide services internally, which utilization review responsibilities to delegate and which to retain, whether to require primary care providers to screen patients for mental health problems, and which quality of care activities to conduct. Because MCOs answer these and other important questions differently, MCO products vary greatly. Therefore, managed behavioral health care should not be viewed generically. Understanding issues related to the access to, the cost of, and the quality of mental health treatment services requires knowledge about the variation in the provision of services owing to both product type and contractual arrangements.

In this chapter, selected key findings are reviewed and related to the interests of particular stakeholders. Overall limitations to the study are described, and suggestions are offered for future studies.

Key Findings and Stakeholder Perspectives

MCOs' provision of mental health services varies across a broad range of dimensions, each of which has important implications for the numerous stakeholders in the delivery system: enrollees, purchasers, policy-makers, providers, and MCOs or MBHOs themselves. Key findings of particular interest to various stakeholders include the following:

Behavioral health contracting arrangements vary greatly depending on the managed care product type. The study found that HMOs are far more likely to contract with specialty MBHOs, while PPOs are the only product type to frequently contract with comprehensive vendors. Employers and other purchasers, as well as consumers, will find this information useful in going beyond traditional managed care labels to consider the specific structures through which mental health care is delivered.
Mental health benefits generally include a broad continuum of care but are typically subject to limits and to cost sharing that is greater than for general medical care. Purchasers, consumers, and policy-makers with an interest in parity will be interested to know that all managed care product types still (in 1999) rely substantially on benefit restrictions to contain costs.
MCOs seldom require standardized screening for mental health problems in primary care settings but frequently provide practice guidelines for mental health treatment in primary care. This should provide important data for dialogue among providers, MCOs, and others concerning how best to improve the diagnosis and treatment of mental health disorders within primary care settings.
Primary care gatekeeping is unusual but does vary by product type. HMOs are most likely to require this, but for all products direct self-referral and phone center referral are typical. Employers and other purchasers as well as consumers should be aware of these differences as they consider which plans best meet their needs.
A substantial proportion of MCOs aim to control aspects of the specialty treatment process such as time to initial appointment and follow-up after inpatient discharge. HMOs and specialty contract products are generally more likely to have such policies. Providers, consumers, employers and other purchasers, and MCOs or MBHOs themselves, can factor this into their assessments of mental health care delivery systems.

Thus, the main findings cover a broad spectrum of areas related to mental health services in MCOs, each particularly salient to certain groups of stakeholders, and all results should prove useful as a benchmarking tool for MCOs themselves. The survey results can shed light on many aspects of the debate about the changing landscape of mental health services under managed care.

Service Delivery Models

As shown, product type and contracting arrangement are associated with certain features of the specialty mental health delivery system. To illustrate, here are two common scenarios based first on product type and then on contracting arrangement.

If an enrollee in a typical PPO product seeks specialty mental health services, he or she will -

Have those services delivered through the PPO's internal network or through a contracted comprehensive network (in contrast to other product types, which usually have specialty contracts).
Not need prior authorization for out-patient care (while HMOs almost always require this).
Lack access to specialized providers or treatment programs for dual mental health and substance abuse disorders (in contrast to HMOs, where this access is more common).
Not be provided some 24-hour crisis services such as phone triage/referral assistance (again in contrast to other product types).

If an enrollee in a typical managed care product with a specialty MBHO contract seeks mental health services, he or she will -

Need prior authorization to access all levels of care (which is more stringent than in other contracting arrangements).
Find that the MBHO is responsible for initial utilization review.
Have access to 24-hour services such as telephone triage/referral.

These are examples of prevalent patterns that the study results have revealed, although there is variation within each product type or contracting arrangement. Thus, it is important to recognize both the general differences and the individual variations that exist.

Interaction of Product Type and Contracting Arrangement

This report has examined separately the effects of product type and of contracting arrangement, capturing the decisions that consumers, employers, and MCOs need to make. For example, when selecting commercial health insurance plans, usually coordinated through their employer, consumers will find it helpful to know how HMO, PPO, and POS plans are likely to operate. Consumers also may wish to inquire further into the mental health contracting arrangements for the health plan, knowing that there are likely to be differences based upon that variable as well.

However, because different product types are more or less likely to choose particular contracting arrangements, the differences observed may be inherent in the product type itself, driven by the contracting arrangement, or affected by both factors. As seen in Chapter V, the distribution of practice guidelines in primary care is lower in PPOs than in HMOs, for instance, but it is not possible to discern whether this is due to some aspect of PPOs themselves or due to PPOs' different contracting arrangements. To explore this issue for targeted topics, we used statistical techniques that allow the effects of both product type and contracting arrangement to be taken into account simultaneously and the independent effect of each to be estimated. Using either logistic or ordinary least-squares regression as appropriate, we analyzed cost-sharing level, primary care screening, availability of dual-diagnosis programs, and use of specialty mental health practice guidelines. In all cases, both product type and contracting arrangement variables had significant independent effects. Thus, both product type and contracting arrangement make a difference across a range of mental health system features.

Limitations

The study is subject to various limitations that should be considered when interpreting its results. First, the study focused on organizational respondents, not individual clients, and therefore cannot address how client experiences and outcomes may vary across the different organizational arrangements. However, information from organizational surveys like this one can be helpful to those designing client studies by focusing on key structural aspects of care delivery. Second, the survey does not include indemnity health plans. Given their dwindling market share, this limitation may be of decreasing importance. Third, on some topics, arrangements may have evolved further since 1999, when this survey was done; for example, prescription drug benefits have changed rapidly with the emergence of three-tier benefit designs. This is one reason for the planned resurvey in 2003.

Future Research

Two major directions are needed in terms of future research. First, an updated examination of the same issues reported on here is needed because of the rapid changes in the context in which MCOs operate, incluing changes in legislation on parity for mental health care, downturns in the economy, and new developments in the clinical treatment of mental health problems. Second, this project has focused on an organizational level by surveying managed care plans and talking with management and clinical decision makers at each MCO. Clearly, the next step will be to relate the findings reported here directly to enrollees' experiences in accessing mental health services, by linking these results with information from surveys of enrollees.

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