Managing Managed Care
The following is an article written by governmental affairs director
Chris Koyanagi and communications director Lee Carty of the Bazelon Center
for Treatment Today magazine (Summer 1996). It is adapted from the book
by the same title published by the Bazelon Center.
Managing Managed Care for Publicly Financed Mental Health Services
Is "managed care" of publicly funded mental health services only an attempt
to rationalize major funding cuts? Or could it enable the public mental health
system to develop successful, widespread organized systems of care?
Managed care systems that agree to provide all necessary care for a fixed
payment have an incentive to deny services or coerce people into accepting
services they may not want. This creates the potential for great harm to those
with high-cost needs. On the other hand, certain aspects of managed care could
signficiantly improve the public mental health system. For example, managed
care can control the use of inpatient and residential services by emphasizing
care in the least restrictive setting of the consumer's choice, substituting
support services for expensive clinical care and fostering efficiency among
provider agencies.
Although people with less severe disorders face important issues in seeking
mental health services, the real challenge is to ensure that managed care approaches
do not result in inappropriate or insufficient services for adults with serious
mental illness and children with serious emotional disturbance who rely for
their care on the public sector.
In general, consumers in the public system have more serious disabilities--often
compounded by extreme poverty--than the privately insured population. Also,
there is a public responsibility; states must remain the agents of last resort
for people with no other access to services. When states contract for managed
care, that responsibility must be built into the contract. Accordingly, managed
care arrangements will need to adopt the basic values that have proven effective
in good public mental health systems.
These values and approaches are articulated in the principles of the federal
Community Support Program for adults with serious mental illness and, for children
with serious emotional disturbance, through the Child and Adolescent Service
System Program's system of care. Public systems built on these values focus
on the individual's recovery and view consumers as partners in treatment and
rehabilitation. Service plans are driven by consumers' goals and build on their
strengths.
Once the decision is made to move to managed care, specifications are needed--in
law, regulations or contracts--to guard against limitations on access, to maintain
the quality of care and to protect consumers' rights and ensure that the system
respects their wishes. Any managed care arrangement must include the following
elements:
- Consumer and family involvement in design, implementation and evaluation
of the managed care plan. This means that consumers, families and advocates
participate in the planning group (commission, task force, workgroup, etc.)
developing the draft plan, that a state-level consumer-oversight board reviews
implementation of managed care, and that the managed care entity conducts
regularly scheduled consumer-satisfaction surveys and uses the results to
improve its services.
- Protection of consumer rights. This means a stated right of consumers
to be fully involved in all treatment decisions, to participate in the development
of their service plan and to refuse any treatment they do not feel is appropriate.
Consumers are also guaranteed the right to file a grievance at any time and
to receive a response within a reasonable time.
- Provision of a full array of truly accessible services, including psychiatric
rehabilitation, case management, assertive community treatment, intensive
in-home services for children, school-based day treatment, consumer-run self-help
and other services necessary to achieve positive outcomes. This requires
the flexibility to use funds for alternatives to inpatient care and ensure
that any "savings" generated remain in the managed care system, to be reinvested
in community alternatives or to expand eligibility to an uninsured population.
- Access to and effective use of community services. This means including,
for a transition period (five years, for example), community public-sector
agencies that are identified by the state mental health authority as essential
providers. The system should provide geographically and culturally accessible
services and conduct targeted outreach to potential and current enrollees,
particularly to individuals who are homeless, who live in isolated areas
or who face other barriers to enrollment or the ongoing receipt of services.
Such outreach is most effective when done regularly by consumers or family
members.
- Limits on involuntary treatment. This means providing a full array of
acceptable treatment alternatives in order to reduce involuntary commitment
and working with police on appropriate diversionary procedures. Above all,
the managed care entity should be financially responsible for mental health
care for any consumer committed to an inpatient facility; this eliminates
any incentive to shift costs to the state by seeking commitment.
- Measures to ensure that financial issues do not undermine the system.
For example, states without the resources to finance the system adequately
may wish to leave public-sector mental health services out of any capitated
managed Medicaid plan for the time being. Or "soft capitation" can allow
some risk-sharing between the managed care entity and the state to cover
expected additional costs. Soft capitation pays the company more if needed
services exceed a specified level. While it attenuates cost-containment,
it also helps remove incentives to dump consumers with more costly care needs
into the public system.
- Blending funds among the various child-serving agencies to develop a single
coordinated system of care for children with serious emotional disturbance.
State mental health spending for children now comes primarily from child
welfare and education. Mental health dollars alone will be inadequate to
underwrite a managed care system.
- Quality assurance and inclusion of meaningful outcome measures (such as
incarceration rates) to evaluate access to services, utilization, consumer
satisfaction and potential problems. Assessments and monitoring information
about the managed care plan should be available to the public.
- Standards for managed care organizations, with selected issues and items
in the managed care contract serving as triggers for sanctions. It is particularly
important to impose sanctions quickly on plans that violate individual rights
or have excess utilization of their grievance and appeals systems.
Evaluations of small-scale managed care and capitated programs operating in
the public mental health system today offer evidence that, with careful planning,
diligent oversight and the active involvement of consumers, families and mental
health advocates, states can obtain the cost-efficiency they want while ensuring
appropriate access and quality of care and giving consumers real choices. However,
advocates and policymakers will need to be assertive. Corporations purchasing
managed behavioral health care make clear exactly what they want;those who
purchase on behalf of the public should be expected to do the same.
© Copyright 1996 Treatment Today.
|
