AROUND THE NETWORK; Managing Managed Care

Findlay, Steven

IN THE VOCIFEROUS public backlash against managed care from both consumers and health providers, “protecting patients’ rights” has become, according to a Time magazine/CNN poll, as hot a vote-getting issue for politicians as saving Social Security or getting tough on crime. Every state in the union now has some sort of patient protection legislation in place. Meanwhile, Republican and Democratic versions of a federal patients’ bill of rights intended to guarantee access to needed health care and emergency room services, guarantee continuity of care and ensure recourse to patients who have been maimed or died as a result of health plan actions, among other things are being debated, promising what has been called a “bloody brawl over managed care” in congress this fall. Mental health care has had its victories, too. The federal Mental Health Parity Act, which provides for parity in the application of certain dollar limits on mental health benefits with dollar limits on medical and surgical benefits, has become law, while similar legislation has passed in 19 states and is pending in 13 others. But how much actual impact this apparent whirl-wind of consumer outrage and legislative thunder will have on the daily work lives of therapists who feel strangled by managed care is another question. Some critics argue that patients’ bill of rights legislation (which is really geared to physical health care, anyway) might even work paradoxically to bring about less choice for patients, less independence for providers than what we have now. “These bills of rights .. . are almost certain to do the opposite of what consumers say they want,” writes Michael Weinstein in The New York Times; they would “tighten the grip of managed care because they impose elaborate record-keeping requirements on the health plans.”

If the impact of patients’ rights bills on mental health are moot, the Federal Mental Health Parity Act that went into effect this year was clearly supposed to end insurance discrimination against mental health care, and remedy the enormous discrepancy between medical and mental benefits in virtually all health plans. But many critics contend that the law is only a feeble stagger in the right direction, an act “so toothless that it will have zero effect on the bottom lines of companies,” according to Laurie Joan Aron in another New York Times report. Under provisions of the law, any company can still entirely opt out of providing mental health benefits (those with fewer than 50 employees aren’t even covered by the law), they can still limit outpatient visits and inpatient days while increasing co-payments for consumers, and they can be exempted if offering equal access to mental health care increases their insurance costs by one percent or more.

Does this mean that the managed behavioral health care industry will roll on implacably as before, unimpeded by the outcry of politicians and consumers? Not necessarily. The reform movement is too new and the state of the managed care industry too unsettled for a clear prognosis. “The trend is very cloudy,” says Herbert Klein, editor and publisher of Managed Care Strategies, who argues that, whatever the future holds, it is still the corporate and organizational customers buying health care contracts for their employees who determine how much treatment anybody gets and there are almost as many different arrangements as their are buyers. “Managed care in companies are now so big, there are so few of them and they cover so many people, that they don’t have a single policy. What they have are hundreds of thousands of contracts with different entities companies, unions, public organizations. The policies they pursue are dependent upon the contract; if the payor is willing to pay for a generous [mental health package], the managed care company is happy to provide better benefits, but if the payor buys a cheap contract, the MCO has to find a way to hold costs down.”

And yet, for all these caveats, some informed participants in the managed care debates do seem to think that some kind of important change is in the wind. They believe the popular suspicion and dislike of managed care and the unquenchable urge of politicians to make hay out of public mood swings will have some positive effect on the world of managed care. When Managed Care Strategies polled 22 managed care leaders and experts on whether they expected health reform laws to have a greater impact on them in the next year or two, 18 answered yes and 13 thought it was already happening.

Take parity laws, for example. Although it is widely conceded that current parity laws don’t in themselves make much difference, they could constitute a powerful precedent for future legislation. “Companies can pervert the intention of the parity laws by offering little-coverage, but still, we’ve got a foot in the door, ” says Elizabeth Edgar, director of state health care for the National Alliance for the Mentally 111. “The bill’s passage is important for raising the issue of mental health care at a national level, creating a law that applies all across the country showing that the federal government has taken a stand; there is now a national floor for mental health care coverage, even though that floor right now is on the third level of the basement garage.”

Furthermore, there are some indications that the managed care industry may be pro-actively responding to the threat of more stringent regulation particularly the potential passage of a federal bill that allows patients to sue them. In Texas and Missouri now, patients can already sue HMOs for malpractice, for example, and there is no reason why mental health malpractice couldn’t also be a target for lawsuits. Thus, some managed care companies seem to be granting more independence to clinicians in order to avoid liability themselves. “Growing legal risks are making it more unattractive for managed care to do utilization review,” says industry health care consultant Brett Steenbarger, assistant professor of psychiatry at the State University of New York (SUNY) Sciences Center in Syracuse. One trend is for managed care companies to pay therapists a predetermined “case rate” for every client, and then allow them to make all the decisions about care, take all the financial risks if the case turns out to be more difficult and time-consuming than originally planned and assume the legal risk if things go radically wrong and the client sues. “The advantage to clinicians is that once they are paid a case rate, they don’t have to get prior authorization for care. It puts them back in the job of deciding who gets what kind of therapy. There is a greater risk for them, but also more independence.” Of course, the managed behavioral health organization always has the final right of review.

Beyond a growing desire to share the legal risks, managed care executives are now heard to maintain that they are eager to pay more attention to therapists’ complaints about micromanagement of clinical decisions and unreasonable limits on patient care. Magellan Behavioral Health, the nation’s largest behavioral health management organization (BHMO) with 60 million enrollees, is experimenting with alternative payment plans for therapists like paying them case rates allowing them more clinical autonomy. Under this kind of arrangement, therapists might be preauthorized for as many as 10 sessions without prior treatment plans. Says Kirk Griffith, senior vice president for clinical network management at Magellan, “The pressure is very real. There is a recognition that we have to give providers more autonomy and focus on improving services to patients.” ValueOptions, the second biggest BHMO, with 20 million enrollees, has launched its own mini-liberation program called CareFirst, in which therapists verify a client’s coverage by phone, determine themselves the number of initial sessions likely to be needed and register the client for them on the spot. “We are eager to move beyond traditional utilization review,” says Nancy Garden, chief marketing officer for ValueOptions. “We believe that providing easier access to care up front can actually reduce the cost of care in the long run.”

STEVEN FINDLAY

MARY SYKES WYLIE

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