Management of behavioral health provider networks in private health plans

We explored the techniques used by private health plans or by their contracted managed behavioral healthcare organizations (MBHOs) to maintain networks of behavioral health providers. In particular, we focused on differences by health plans' product types (health maintenance organization, point-of-service plan, or preferred provider organization) and contracting arrangements (MBHO contracts, comprehensive contracts, or no contracts). More than 94% of products selected providers using credentialing standards, particular specialists, or geographic coverage. To retain providers viewed as high quality, 54% offer reduced administrative burden and 44% higher fees. Only 16% reported steerage to a core group of highest-quality providers and few reported an annual bonus or guaranteed volume of referrals. Some standard activities are common, but some health plans are adopting other approaches to retain higher-quality providers.     

The influence of patient characteristics on ratings of managed behavioral health care

Despite current emphasis on consumer-based performance measures, little is known about factors that influence consumer ratings of behavioral health care. This study examines the influence of patient characteristics, health care use, and insurance coverage on patients' ratings of their managed behavioral health care in both commercial and public plans. Older and healthier patients rated their behavioral health care and health plan more highly than did other patients. Patients with less education and those whose insurance paid all costs of care gave consistently higher plan ratings. Women and frequent users enrolled in commercial plans gave more positive care ratings. After adjusting for enrollee characteristics and coverage, there were no differences between ratings of patients in commercial and public plans. These results are consistent with other research that illustrates the importance of adjusting health care ratings for patient characteristics when comparing plans.The views expressed in this article are those of the author and do not necessarily represent the views of the Department of Veterans Affairs.     

The role of managed care in integrated delivery networks

Health care reform, especially if as anticipated via a capitated payment system, will lead providers to integrate the services they provide to the community with those of other organizations. Vertical integration strategies, such as the formation of physician-hospital organizations, and horizontal integration through alliances and holding companies, are the primary vehicles that hospitals and other providers will use to establish integrated networks. By including insurers and primary care physicians in the network and developing information systems to support the delivery of high quality, cost-effective services, the networks can offer a full continuum of care and minimize service duplication.     

The effect of narrow provider networks on health care use

Network design is an often overlooked aspect of health insurance contracts. Recent policy factors have resulted in narrower provider networks. We provide plausibly causal evidence on the effect of narrow network plans offered by a large national health insurance carrier in a major metropolitan market. Our econometric design exploits the fact that some firms offer a narrow network plan to their employees and some do not. Our results show that narrow network health plans lead to reductions in health care utilization and spending. We find evidence that narrow networks save money by selecting lower cost providers into the network.     

Evaluating quality in managed care networks

If managed care is to succeed, methods for evaluating individual networks are essential. The author outlines crucial areas of the evaluation process, including rights, responsibilities, and ethics; continuum of care; education and communication; network leadership; human resources management; management of information; and performance improvement. Public disclosure of such evaluations is necessary to ensure their efficacy.     

Risk sharing in managed behavioral health care.

While policymakers have expressed concern over the impact of risk sharing with providers on treatment patterns, the literature lacks decisive evidence on which to base policy. This paper evaluates the impact of a contracting change within a managed behavioral health organization from a fee-for-service system to a case-rate system with utilization management delegated to providers. The contracting change resulted in a 25 percent reduction in mental health visits per episode. This effect varies with the dollar amount of the case rate and is more pronounced for providers with a larger share of revenue from risk contracts and with intensive utilization management programs.     

Sex of provider as a variable in effective genetic counseling

Selected aspects of the interaction in genetic counseling sessions, as reported by women patients seen by a female provider, were compared to the interaction reported by women patients seen by a male provider. Although counseling sessions were comparable in terms of length of time, significantly more in-depth discussion of selected medical and genetic topics was reported when the provider was female; more discussion was reported of medical and genetic topics which patients came to counseling to discuss when the provider was female; and women patients reported a greater willingness to raise issues of concern in counseling when the provider was female. Women patients also were more likely to report the explanations offered by female providers as clearer than those offered by male providers. In general the data suggest that women patients in genetic counseling receive a somewhat different and less comprehensive type of counseling when seen by a male as opposed to a female provider. Analysis suggests that the differences observed may be due less to variation between male and female providers in terms of professional preparation than to variation in how male as opposed to female providers orient themselves to women patients, as well as to how women patients orient themselves to female as opposed to male providers.     

Regulating risks: consumer protections in provider health networks

As competition for health care dollars grows fierce, physicians and hospitals are going head to head with insurance companies. They are forming new partnerships, broadly called provider-sponsored organizations, that cut out the middleman and have the potential to furnish better care at lower prices. But legislators, regulators, and consumers must understand the dangers inherent in the structure of some PSOs.