The impacts of mental health parity and managed care in one large employer group: a reexamination

Although the impacts of carve-outs to managed behavioral health care organizations (MBHOs) and parity mandates on costs are largely settled in the literature, their impacts on access are less clear. Here we reexamine a study published by Samuel Zuvekas and colleagues in this journal, which found that the number of people receiving mental health/substance abuse treatment increased by almost 50 percent after the introduction of mental health parity and an MBHO. Using multivariate panel data methods, we now suggest that secular trends were largely responsible for this increase.     

Integrating mental health services through reimbursement reform and managed mental health care

People with serious and persistent mental illness require a range of community services typically provided by different specialized agencies. At the clinical level, assertive team case management is the strategy commonly used to achieve integration of services across specialized sectors. The USA also has used various financial and organizational approaches to reduce fragmentation and increase effectiveness, including development of stronger public mental health authorities, use of financial incentives to change professional and institutional behavior, requirements to allocate savings from hospital closures to community systems of care, and introduction of mental health managed care on a broad scale. These approaches have potential but also significant problems and there is often a large gap between theory and implementation. These US developments are discussed with attention to the implications for mental health services in the UK.     

How mental health providers see managed care

This paper reports findings from two focus groups on managed care conducted in a large U.S. city in 1989. Questions addressed included how managed care had affected mental health practice, specific experiences with managed care, the mechanisms of managed care, and how managed care could be improved. The practitioners complained of multiple problems, but clearly distinguished between “good” and “bad” firms. Firms seen as more positive struck a balance between quality care and cost containment, built ongoing relationships with providers, and negotiated with providers, rather than prescribing a treatment plan. The authors conclude that some of the poor reception by providers of managed care may have been created unnecessarily by firms which have not attended to those factors, and that attention to such factors might lead to a more ready acceptance of managed care.     

Provider turnover in public sector managed mental health care

The present study examines the extent of turnover in mental health provider networks within public sector managed mental health care over a 1-year period and its association to provider and practice characteristics. Telephone interviews were conducted with a sample of mental health services providers listed the previous year in the networks of the 3 public sector managed mental health care organizations operating in Puerto Rico. Thirty-one percent of respondents had dropped out of networks. The drop-out rate was significantly associated (P.05) with increasing number of years in practice and decreasing years under contract. A nonsignificant trend was observed, suggesting that providers with subspecialty training are less likely to drop out. The results may be signaling an emerging problem in public sector managed mental health care. Stability of provider networks should be monitored by state agencies contracting out mental health care.     

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.     

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.     

Rethinking professional prerogative: managed mental health care providers

Managed care represents a response to the wider institutional demand for technical rationality and efficiency. In the US, managed care exemplifies the commodification of health and is governed by a technocratic-rationality that often conflicts with the professionally governed value rationality of providers. Providers must negotiate between contradictory institutional demands for cost containment and quality care in their everyday work practices, and consequently experience a series of ethical dilemmas. This paper examines the effect the commodification of health care has had upon the work of mental health care providers, their loss of professional prerogative, their concrete experience of the ethical dilemmas which result from the commodification of care, and evidence of countervailing power.     

The evaluation of a children’s mental health managed care demonstration

This article introduces the Fort Bragg managed care experiment. This study was a 5-year, $80 million effort to evaluate the cost-effectiveness of a full continuum of mental health services for children and adolescents. The article describes the development of the Demonstration, the program theory underlying intervention, and how this theory was tested.     

Pragmatics of tracking mental health outcomes in a managed care setting

Accountability, cost effectiveness, and continuous quality improvement are essential features of all managed health care systems. However, application of these principles to mental health treatments has lagged behind other health care services. In this article, administrative, practice, and technical issues are addressed through a joint effort between academically based researchers and administrators from two large managed health care organizations. Principles related to the measurement of outcome, instrument selection, and obstacles to the implementation of an ongoing program to assess mental health treatment outcomes are identified. Finally, principles for successfully changing mental health provider behavior toward outcome assessment and the implications of such for mental health delivery systems are discussed.     

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.     

Considerations in predicting mental health care use: Implications for managed care plans

Managed care plans and other health care providers face a difficult task in predicting outpatient mental health services use. Existing research offers some guidance, but our knowledge of which factors influence use is confounded by methodological problems and sampling constraints. Consequently, available findings are insufficient for developing accurate predictions, which managed care plans need in order to formulate fiscally responsible service delivery contracts. This article reviews the primary data sources and research on ambulatory mental health services. On the basis of this review, the probability and intensity of outpatient visits are estimated. The primary predictors of use are also examined because they may help managed care plans forecast use by a given population or group of enrollees. Gender, age, race, education, health status, and insurance coverage are several variables surfacing as statistically significant predictors of use. The implications for planning capitated mental health services are discussed.     

Medicaid managed care for mental health services in a rural state

State governments throughout the country increasingly have turned to managed care for their Medicaid programs, including mental health services. We used ethnographic methods and a review of legal documents and state monitoring data to examine the impact of Medicaid reform on mental health services in New Mexico, a rural state. New Mexico implemented Medicaid managed care for both physical and mental health services in 1997. The reform led to administrative burdens, payment problems, and stress and high turnover among providers. Restrictions on inpatient and residential treatment exacerbated access problems for Medicaid recipients. These facts indicate that in rural, medically underserved states, the advantages of managed care for cost control, access, and quality assurance may be diminished. Responding to the crisis in mental health services, the federal government terminated New Mexico's program but later reversed its decision after political changes at the national level. This contradictory response suggests that the federal government's oversight role warrants careful scrutiny by advocacy groups at the local and state levels.