Changes in How Health Plans Provide Behavioral Health Services

Health plans appear to be moving toward less stringent management, but it is not known whether behavioral health care arrangements mirror the overall trend. To improve access to and quality of behavioral health services, it is critical to track plans’ delivery of these services. This study examined plans’ behavioral health care arrangements and changes over time using a nationally representative health plan survey regarding alcohol, drug abuse, and mental health services in 1999 (N = 434, 92% response) and 2003 (N = 368, 83% response). Findings indicate health plans’ behavioral health service provision changed significantly since 1999, including a large increase in contracting with managed behavioral health care organizations. Some evidence of loosening administrative controls such as prior authorization implies easier access to services. However, increased prevalence of higher levels of cost sharing suggests financial barriers have grown. These changes have important implications for enrollees seeking care and for providers working to meet patients’ needs. This study was supported by the National Institute of Drug Abuse grant #R01DA10915 and the National Institute on Alcohol Abuse and Alcoholism grant # R01AA10869. The 1999 round was also supported by the Substance Abuse and Mental Health Services Administration contract #98M-0028601.     

Underinsurance for Recently Recommended Vaccines in Private Health Plans

Underinsurance for vaccines presents financial barriers to vaccination. Preventive services coverage is of interest in national healthcare reform. To assess vaccine benefits coverage in private health plans. Private health insurance carriers were surveyed December 2008–June 2009 on policies regarding vaccine coverage in fully insured plans. Carriers were identified as multi-state, state-specific Blue Cross or local-independent carriers. Plan types included HMO, PPO, POS and ‘other.’ Full benefits coverage was defined as having benefits without a copay or coinsurance for a recommended vaccine. Analyses were conducted to examine associations between carrier type, plan type, and full benefits coverage. Fifty-one carriers (response rate?=?56?%) provided data for 78 unique plans, reflecting over 47 million private plan enrollees. Full benefits coverage was highest for combined tetanus/diphtheria/acellular pertussis (74?%) and lower for pneumococcal conjugate (72?%), rotavirus (72?%), human papillomavirus (71?%), hepatitis A (68?%), meningococcal conjugate (67?%), inactivated influenza (67?%), live attenuated influenza (63?%) and zoster (57?%) vaccines. Compared with plans offered by state-specific Blue Cross carriers, significantly higher proportions of multi-state carriers and local independent carriers had plans with full benefits coverage for vaccines (p?<?0.05). Compared with PPO and “other” plans, significantly higher proportions of HMO and POS plans had full benefits coverage for vaccines (p?<?0.05). In this national study, levels of underinsurance for immunization leave room for improvement. State-specific Blue Cross plans and indemnity or high-deductible plans are least likely to offer full coverage for recently recommended vaccines, and may face changes with incorporation of “essential health benefits” requirements.     

Peer Reviewed: Systems-Level Smoking Cessation Activities by Private Health Plans

Introduction

The US Public Health Service urges providers to screen patients for smoking and advise smokers to quit. Yet, these practices are not widely implemented in clinical practice. This study provides national estimates of systems-level strategies used by private health insurance plans to influence provider delivery of smoking cessation activities.

Methods

Data are from a nationally representative survey of health plans for benefit year 2003, across product types offered by insurers, including health maintenance organizations (HMOs), preferred provider organizations, and point-of-service products, regarding alcohol, tobacco, drug, and mental health services. Executive directors of 368 health plans responded to the administrative module (83% response rate). Medical directors of 347 of those health plans, representing 771 products, completed the clinical module in which health plan respondents were asked about screening for smoking, guideline distribution, and incentives for guideline adherence.

Results

Only 9% of products require, and 12% verify, that primary care providers (PCPs) screen for smoking. HMOs are more likely than other product types to require screening. Only 17% of products distribute smoking cessation guidelines to PCPs, and HMOs are more likely to do this. Feedback to PCPs was most frequently used to encourage guideline adherence; financial incentives were rarely used. Furthermore, health plans that did require screening often conducted other cessation activities.

Conclusion

Few private health plans have adopted techniques to encourage the use of smoking cessation activities by their providers. Increasing health plan involvement is necessary to reduce tobacco use and concomitant disease in the United States.     

Organizational Leaders Perceptions of Barriers to Accessing Behavioral Health Services in a Low-Resource Community

The Journal of Behavioral Health Services & Research - Little is known about how to effectively implement behavioral health programs in low-resource communities. Leaders from 20...     

Predictive Modeling in Health Plans

Predictive modeling in healthcare has been gaining more interest and utilization in recent years. The tools for doing this have become more sophisticated with increasingly higher accuracy. We present a case study of how artificial intelligence (AI) can be used for a high quality predictive modeling process, and how this process is used to improve the quality and efficiency of healthcare. In this case study, MEDai, Inc. provides the analytical tools for the predictive modeling, and Sentara Healthcare uses these predictions to determine which members can be helped the most by actively looking for ways to prevent future severe outcomes. Most predictive methodologies implement rule-based systems or regression techniques. There are many pitfalls of these techniques when applied to medical data, where many variables and many interactive variable combinations exist necessitating modeling with AI. When comparing the R² statistic (the commonly accepted measurement of how accurate a predictive model is) of traditional techniques versus AI techniques, the resulting accuracy more than doubles. The cited publications show a range of raw R² values from 0.10 to 0.15. In contrast, the R² value obtained from AI techniques implemented at Sentara is 0.34. Once the predictions are generated, data are displayed and analytical programs utilized for data mining and analysis. With this tool, it is possible to examine sub-groups of the data, or data mine to the member level. Risk factors can be determined and individual members/member groups can be analyzed to help make the decisions of what changes can be made to improve the level of medical care that people receive.     

Unmet Need and Problems Accessing Specialty Medical and Related Services Among Children with Special Health Care Needs

OBJECTIVES: To extend what is known about parent reports of their child's need for specialty medical and related services, unmet need, and specific types of access problems among children with special health care needs (CSHCN). METHODS: Using data from a 1998-1999 20-state survey of families of CSHCN, we examined differences in parent report of need for services by child characteristics, investigated parent report of unmet need and access problems by service area and number of services needed, and estimated the likelihood of four access problems and unmet need by child, family, and health insurance characteristics. RESULTS: Overall, the sample children had numerous service needs, although the prevalence of need varied by service type and child characteristics. Reports of unmet need were greater for older children and for children with multiple service needs, unstable health care needs or a behavioral health condition, parents who were in poor health or had more than a high school education, and families whose insurance coverage was inconsistent or lacked a secondary plan. Reports of access problems were greatest for mental health and home health services. The two most prevalent access problems were finding a skilled provider and getting enough visits. CONCLUSIONS: The results underscore the importance of finding new ways to link children with behavioral health problems to mental health services, implementing coordinated care and the other core dimensions of the medical home concept, increasing the number of specialty pediatricians and home health providers, and expanding coverage for a wider range of mental health services.     

Health Plans and Disease Management

Health plans are committed to the advancement of disease management (DM). They believe DM is crucial to the successful management of care, and actively promote a variety of DM initiatives. However, the political climate in the US in recent years has not been conducive to the advancement of managed care, and thus threatens the advancement of DM as well. On the other hand, voters have recently demonstrated a lack of sympathy with critics of managed care, and despite a contentious debate over patientss’ rights, there is growing awareness of the benefits of evidence-based care, particularly in managing chronic conditions to improve quality of life and productivity. This awareness, although perhaps overshadowed by the current political scene, creates important opportunities for DM advocates.     

Disruptive Innovation: Value-Based Health Plans

Value and a Complex Healthcare Market

What Is Value to an Employer?

“Worth in usefulness or importance to the possessor; utility or merit.”American Heritage Dictionary“A principle, standard, or quality considered worthwhile or desirable.”American Heritage Stedman''s Medical Dictionary“A fair return or equivalent in goods, services, or money for something exchanged.”Merriam-Webster''s Dictionary of LawLike the everyday person, defining value for a payor of healthcare services varies depending on your perspective and application of the meaning. For a patient or employee, value means there is some worth in the usefulness of the subject or importance to possessing it. To a clinician, value relates to a standard of quality or a principle that is not only worthwhile, but also desirable. For an attorney, value is defined in contractual terms connoting an economic exchange or equivalence in goods or services. Thus, it is important for an employer, as a payor of healthcare services, to define value and its resulting business proposition to the organization''s mission or goals.Healthcare has traditionally been a contracted services arrangement for employers who “purchase” it through health plans and/or pharmacy benefit managers (PBMs). Costs for these services, however, have grown over time along with continual double-digit increases in the cost associated for a healthcare plan that is purchased (fully insured) or funded through a self-insurance plan. Consequently, there is intense interest in the value associated with a health plan for the business enterprise and its associated value proposition.     

Behavioral Health Treatment Receipt Among a Community Sample of Young Adult Veterans

Young adult veterans are at risk for behavioral health problems such as depression, posttraumatic stress disorder (PTSD), and substance misuse. Despite this, studies of veterans within the Veterans Affairs Healthcare System (VA) indicate that about half of those warranting treatment receive it in any form, with few receiving an adequate dose of care. For this study, the behavioral health screening status and behavioral health usage (including care outside of VA settings) among a community sample of 812 young adult veterans recruited from the Internet is described. Although approximately 70% of the sample screened positive for behavioral health problems, only one fifth to three fifths of those screening positive reported any mental health or substance use treatment in the past year, with one third or less receiving a dose of minimally adequate psychotherapy or psychotropic care. Findings expand on prior work and suggest that more effort is necessary to engage young veterans in behavioral health services.     

Switching Health Insurance Plans: Results from a Health Survey

The study is designed to provide an informal summary of what is known about consumer switching of health insurance plans and to contribute to knowledge about what motivates consumers who choose to switch health plans. Do consumers switch plans largely on the basis of critical reflection and assessment of information about the quality, and price? The literature suggests that switching is complicated, not always possible, and often overwhelming to consumers. Price does not always determine choice. Quality is very hard for consumers to understand. Results from a random sample survey (n = 2791) of the Alkmaar region of the Netherlands are reported here. They suggest that rather than embracing the opportunity to be active critical consumers, individuals are more likely to avoid this role by handing this activity off to a group purchasing organization. There is little evidence that consumers switch plans on the basis of critical reflection and assessment of information about quality and price. The new data reported here confirm the importance of a group purchasing organizations. In a free-market-health insurance system confidence in purchasing groups may be more important for health insurance choice than health informatics. This is not what policy makers expected and might result a less efficient health insurance market system.