Selection in a preferred provider organization enrollment.

OBJECTIVE. The study was conducted to determine whether favorable or adverse selection occurred in a preferred provider organization (PPO) enrollment. DATA SOURCES AND STUDY SETTING. Secondary data sources were used to conduct a retrospective study of the utilization of health services and the demographic characteristics of the population involved in the first open enrollment in a new university-based PPO. The PPO under study, sponsored by the University of Michigan (UM) Medical Center, was offered to all 43,005 UM employees, dependents, and retirees. STUDY DESIGN. We analyzed insurance company payments during the one-year period prior to the enrollment to compare the utilization patterns of those who enrolled in the PPO with those who did not. DATA COLLECTION. Prior health care utilization data were obtained from Blue Cross-Blue Shield of Michigan on the entire university population for one year prior to the start of the PPO. Demographic data were obtained from the personnel office of the university. PRINCIPAL FINDINGS. The PPO group had a younger median age than the non-PPO group; the sex distribution was roughly similar for the two groups. In the PPO group 57 percent of all contracts were family contracts compared with only 30 percent in the non-PPO group. The PPO group experienced 20.6 percent lower inpatient payments per member, and 9.4 percent lower outpatient payments per member in the year prior to the enrollment. These differences resulted in an overall 18.7 percent lower payment per member for the PPO group in the year prior to their enrollment. CONCLUSIONS. The results show, based on prior insurance payments, that this PPO received favorable selection during the open enrollment, a finding consistent with favorable selection found in early HMO enrollment.     

Parity for mental health and substance abuse care under managed care

BACKGROUND: Parity in insurance coverage for mental health and substance abuse has been a key goal of mental health and substance abuse care advocates in the United States during most of the past 20 years. The push for parity began during the era of indemnity insurance and fee for service payment when benefit design was the main rationing device in health care. The central economic argument for enacting legislation aimed at regulating the insurance benefit was to address market failure stemming from adverse selection. The case against parity was based on inefficiency related to moral hazard. Empirical analyses provided evidence that ambulatory mental health services were considerably more responsive to the terms of insurance than were ambulatory medical services. AIMS: Our goal in this research is to reexamine the economics of parity in the light of recent changes in the delivery of health care in the United States. Specifically managed care has fundamentally altered the way in which health services are rationed. Benefit design is now only one mechanism among many that are used to allocate health care resources and control costs. We examine the implication of these changes for policies aimed at achieving parity in insurance coverage. METHOD: We develop a theoretical approach to characterizing rationing under managed care. We then analyze the traditional efficiency concerns in insurance, adverse selection and moral hazard in the context of policy aimed at regulating health and mental health benefits under private insurance. RESULTS: We show that since managed care controls costs and utilization in new ways parity in benefit design no longer implies equal access to and quality of mental health and substance abuse care. Because costs are controlled by management under managed care and not primarily by out of pocket prices paid by consumers, demand response recedes as an efficiency argument against parity. At the same time parity in benefit design may accomplish less with respect to providing a remedy to problems related to adverse selection.     

Low-income women's use of substance abuse and mental health services

This paper examines the utilization of mental health, alcohol, and drug treatment in a sample of low-income women. We analyze data from the Women's Employments Study, a study examining the barriers to employment for welfare recipients, and compare prevalence rates of mental health disorders and service utilization with the National Comorbidity Survey. Fewer than one in five of the respondents with a current mental health and/or substance dependence problem in the Women's Employment Study (WES) received treatment in the past 12 months. A logistic regression model of the association among demographic variables, risk factors, and service utilization in the WES found that having a co-occurring substance dependence and mental health disorder was significantly associated with receiving treatment. Those respondents with an increased number of barriers were significantly less likely to receive treatment. The authors argue that the success of welfare reform may hinge on low-income women's access to and utilization of appropriate services.     

State substance abuse and mental health managed care evaluation program

The articles in this special section of the Journal of Behavioral Health Services & Research (30:1) present results from evaluations of publicly funded managed care initiatives for substance abuse and mental health treatment in Arizona, Iowa, Maryland, and Nebraska. This overview outlines the four managed care programs and summarizes the results from the studies. The evaluations used administrative data and suggest a continuing challenge to structure plans so that undesired deleterious effects associated with adverse selection are minimized. Successful plans balanced risk with limited revenues so that they permitted greater access to less intensive services. Shifts from inpatient services to outpatient care were noted in most states. Future evaluations might conduct patient interviews to examine the effectiveness and quality of services for mental health and substance abuse problems more closely.     

Analysis & commentary: The case for measuring quality in mental health and substance abuse care

Over the past decade, efforts to measure and improve quality have permeated health policy and health care generally but have barely penetrated mental health and substance abuse care. We review barriers and recent activities in these areas and propose a short list of quality measures to engage the policy and practice community in a discussion about how best to evaluate the care of people with these conditions. Quality measures could include, for example, screening, brief intervention, and referral for alcohol abuse. Because proposing a list is only a first step, we suggest other elements of a broader strategy to bring mental health and substance use care into the mainstream of health care quality improvement.     

Clients with substance abuse and mental health concerns: A guide for conducing intake interviews

Although comorbidity (co-occurrence of a psychiatric and substance use disorder) is a common phenomenon at both mental health and substance abuse treatment agencies, rarely do such agencies thoroughly assess for both types of diagnoses during their standard intake interview. This article describes the development of an intake form designed to guide a comprehensive assessment of both mental health and substance abuse concerns. The form guides intake interviewers toward documenting administrative and demographic information, substance use and mental health concerns, and variables needed for compliance with grant funding sources. Use of the protocol can provide a clinical foundation for treatment planning and continuity of care for clients, while also providing error-free agency data that can be used for administrative, program planning, outcome assessment, and research purposes.     

A new approach to preferred provider selection in health care

In January 2015 Zilveren Kruis, the largest health insurer in The Netherlands, engaged in a new three-year, unlimited volume contract with five carefully selected providers of cataract surgery. Zilveren Kruis used a novel method, designed to identify the top expert providers in a certain discipline. This procedure for provider selection uses the principles of Best Value Procurement (BVP), and puts the provider in charge of defining key performance indicators for health care quality. The procedure empowers the professional and acknowledges that the provider, not the purchaser, is the true expert in defining what is high quality care. This new approach focuses purely on provider selection and is thus complementary to innovations in health care reimbursement, such as value-based hospital purchasing or outcome-based financing. We describe this novel approach to preferred provider selection and show how it makes affordable quality the core topic in negotiations with providers.     

Perceptions of mental health and substance abuse program administrators and staff on service delivery to persons with co-occurring substance abuse and mental disorders

Several initiatives in the past 20 years have been implemented in Los Angeles County to improve service delivery across the mental health and substance abuse treatment systems, with the goal of increasing access to and coordination of services for individuals with co-occurring substance abuse and mental disorders. To examine the current status of service delivery to this population, a survey was conducted with administrators of mental health and substance abuse programs that provide services to dually diagnosed patients and with the treatment staff in those programs. Administrators (n=15) and staff (n=99) in substance abuse programs rated the accessibility and coordination of services to dually diagnosed patients significantly lower than the mental health administrators (n=10) and staff (n=136). Efforts to coordinate service delivery across the two systems need to address these divergent perceptions between staff in programs that are increasingly called upon to work together to jointly deliver services.when this work was completed     

Medicare preferred provider organization demonstration: plan offerings and beneficiary enrollment

As preferred provider organizations (PPOs) become the dominant model of managed health care in the private sector, policymakers have increasingly viewed PPOs as an attractive option for Medicare. In part to understand how PPOs might operate under the Medicare Program, CMS launched the Medicare PPO demonstration in January 2003. In this article, we examine how PPOs have operated so far under the demonstration, including PPO availability and market entry; premiums, benefits, and beneficiary cost sharing; and enrollment, market share, enrollee characteristics, and disenrollment to date.     

Preventive mental health and substance abuse programs and services in managed care

If effective preventive behavioral health services were available to the millions of Americans enrolled in managed care organizations, the public health impact could be significant. This project sought to summarize published research-based information about effective preventive interventions for mental health and substance use (tobacco, alcohol, and other drugs) shown or likely to have no negative cost impact. Fifty-four studies satisfied seven screening criteria. Their findings demonstrated that preventive behavioral health interventions appropriate for managed care settings have been evaluated and have been shown to be effective. Some produced cost savings or offset costs. Six preventive behavioral health interventions are therefore recommended for managed care.     

Establishing a capitation policy for mental health and substance abuse services in healthcare reform

In healthcare reform the evolution toward capitated payment systems raises many questions that are unique to behavioral healthcare providers. These issues include how to structure risk contracts, how to set appropriate prices and how to price and cover the severely mentally ill and uninsured. Two possible solutions to the pricing dilemma are described in this article: using prior-use experience for setting prices, with a DRG-type classification formula, and using a combination of past-use formulas and current utilization data.     

Spending on mental health and substance abuse treatment, 1987-1997

This paper is the result of an ongoing effort to track spending on mental health and substance abuse (MH/SA) treatment nationwide. Spending for MH/SA treatment was $85.3 billion in 1997: $73.4 billion for mental illness and $11.9 billion for substance abuse. MH/SA spending growth averaged 6.8 percent a year between 1987 and 1997, while national health expenditures grew by 8.2 percent.