The following is in response to the interview "The Scourge of Managed Care" with Harold Eist, president of the American Psychiatric Association, which appeared in the Spring, 1997 issue of Paradigm.
Harold Eist's emotional tirade of inaccuracies, exaggerations and untruths do not well serve people with mental illness and addictive disorders, the providers who treat them, nor the process of healthcare reform facing our society. In reply to Dr. Eist, this perspective attempts to outline the objectives of managed behavioral healthcare1,2 as well as to explain some of the difficult and complex challenges the entire behavioral healthcare field faces.3
Yes, there are significant problems with managed care as practiced today. Many of these problems are based on discriminatory insurance coverage for mental illness and addictive disorders, professional and societal disagreement over the medical nature of non-illness emotional and life-adjustment situations,4 and inadequate capitation payments by payers. Dr. Eist pretends that suicide, treatment failures, inappropriate and excessive hospitalizations, and open-ended nonfocused psychotherapy never happened under the previous unmanaged, solo practice, fee-for-service system and in our nation's public mental health system prior to the advent of managed care.
Under managed care, we have for the first time the means to systematically track unfortunate events and thereby determine how they can be prevented.
Among the objectives of managed behavioral healthcare are the following:
Dr. Eist, should we remain aloof from the rest of healthcare and deny coordination of care to those with behavioral disorders?
Payers -- both private and public -- have placed cost restraints on behavioral health services and all health expenditures. Within these cost restraints, payers want accountable delivery -- clinical outcomes, health plan consumer/enrollee/patient satisfaction and coordinated care. This is not a conspiracy by corporations and insurance companies as Dr. Eist accuses, but a movement toward value purchasing. CHAMPUS, Medicaid, Medicare and state and local governments are restraining expenditures, asking that our field document treatment effectiveness, and they are demanding accountability.
Given this resource-based care reality, managed behavioral health organizations are pioneering performance measurements. Examples are the American Managed Behavioral Healthcare Association (AMBHA) PERMS, the National Committee on Quality Assurance (NCQA) HEDIS, and the U.S. Department of Health and Human Services Center for Mental Health Services MHSIP measures.
The Institute of Medicine, National Academy of Science3 has concluded that better methods are needed to evaluate the quality of managed behavioral care. We agree. Denying the need to be accountable will not enhance documented quality, nor will it enhance our goals of equal benefits for those needing treatment for behavioral health illnesses.
A major dilemma faced by public policy makers today involves potential breaches of confidential medical records. According to Dr. Eist, no one should ever see the provider's treatment record. But payers -- including public payers -- are demanding treatment effectiveness and documented clinical accountability. Historically, we have had inappropriate and excessive hospitalizations, open-ended nonfocused psychotherapy and medication mishaps. Clinical review of care by appropriately trained and credentialed reviewers is one method to better ensure accountability and appropriateness of care, while also assisting in the coordination of interventions to treat the whole person.
Dr. Eist claims that managed behavioral healthcare executives earn "salaries of $15 million, $20 million, and a billion dollars." And further that medical directors "are laughing all the way to the bank." It is always interesting to see solo practice fee-for-service psychiatrists earning $100,000 to $150,000 resent a medical director psychiatrist managing complex integrated delivery networks serving millions of enrollees earning $185,000 to $250,000. These inflammatory statements are not accurate and serve no useful purpose.
Society has chosen not to limit profit by either organizations or solo practitioners, but standardization of compensation is an option. More appropriate responses to profit are risk corridors, profit tied to performance, profit caps, reinvestment requirements, taxes paid and contract competition.
Dr. Eist claims that managed care has "reduced services, reduced access and kicked back money saved to the corporation." But the experience is quite the opposite.
The experience of countless payers such as Digital, Bell South, Massachusetts Medicaid, CHAMPUS, New York State Public Employees, Colorado Medicaid, Iowa Medicaid, Oregon Health Plan, Du Pont, Dow, McDonnell Douglas and Federal Express are the same: under managed care more people receive behavioral health services than in pre-managed care, inpatient hospitalizations decline, solo practice psychotherapy declines, a more comprehensive and flexible array of services are provided (day treatment, crisis beds, psychiatric rehabilitation, residential treatment, consumer/peer support, clubhouses and similar social supports), services are better coordinated and expenditures significantly decline.
What to do with the savings is a societal public-policy issue. Is Dr. Eist entitled to "a larger share of the healthcare dollar" for himself and his patients, or does the entire behavioral healthcare field have to document that these services have value -- that they are cost effective? Behavioral health and healthcare in general are in competition with education, transportation, infrastructure, etc. The only way our field will get a greater portion of available dollars is to document effectiveness and accountability.
Dr. Eist claims that consumer/enrollee/patient satisfaction has no value. If this is true, why do all the major consumer and family advocates insist that health plans, their management agents and their providers document consumer responsiveness and satisfaction? Why is the national government's Agency for Health Care Policy and Research (AHCPR) launching the Consumer Assessments of Health Plans Study (CAHPS)? Moreover, is he suggesting that what consumers think has no value?
What do consumers -- not solo practice providers -- say they want? Consumers say they want recovery from illness and disability, choice in treatment alternatives and respect from all providers in the system.5 Respect includes paying attention to what satisfies them.
Resource-based care -- the demand of both public and private payers -- requires clarity of payment responsibility, standardization of medical necessity definitions and criteria, and documented accountability for treatment effectiveness.
Our society is faced with enormous challenges and decisions for the future. In the area of behavioral health, we must press forward for equality of benefits and access. To do so requires the demonstration of value for the resources used. Is Dr. Eist suggesting that we return to a discriminatory benefit using solo practice fee-for-service with no case management and coordination and a second-class public mental health system? I hope not. We need to move to an integrated delivery system with open, flexible benefits and accountability for clinical outcomes and consumer satisfaction.
The author appreciates the ideas and edits offered by Keith Dixon, Ph.D., David Nace, M.D., and Ian Shaffer, M.D. They serve as the 1997 chair, chair-elect and immediate-past chair of AMBHA.
References
1. Ross, E. Clarke, "Managed Behavioral Health Care Premises, Accountable Systems of Care, and AMBHA's PERMS," Evaluation Review, pgs. 318-321, (June 1997).
2. Shaffer, Ian, "Trends In Behavioral Health: Outcomes Management, Integrated Systems, and Patient-Centered Care," Managed Care Week, Perspectives, pgs. 1-4, (May 5, 1997).
3. Institute of Medicine, National Academy of Science, "Managing Managed Care: Quality Improvement In Behavioral Healthcare," (November 1996).
4. Ross, E. Clarke, "Quality of Care: Lack of Consensus on 'Medical Necessity' Hampers Managed Behavioral Healthcare," BNA's Managed Care Reporter, pgs. 1171-1172, (December 11, 1996).
5. Kaufman, C. and Mandersheid, R., "The Consumer-Oriented Mental Health Report Card," Behavioral Healthcare Tomorrow, pgs. 56-57, (April 1997).
E.
Clarke Ross is the executive director of the American Managed
Behavioral Healthcare Association (AMBHA) and adjunct associate
professor of health services administration, University of Maryland.
© 1997 Targeted Publications Group, Inc. All rights reserved.
