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C

Consumer Outcomes and Managed Behavioral Health Care: Research Priorities

Donald M. Steinwachs

Center for Research on Services for Severe Mental Illness, Health Services Research and Development Center, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health

The growth in managed care and managed behavioral health care, with their incentives to reduce costs, has raised concerns that active management of utilization may lead to poorer quality of care and to poorer outcomes for persons with mental illness. The current evidence suggests that substantial cost savings are being achieved by managed care, but with patient outcomes that are no worse than those in the fee-for-service system (Iglehart, 1996). However, many concerns are being raised about the potential for adverse consequences as managed behavioral health care expands to cover more seriously ill and disabled populations (Mechanic et al., 1995). It is the purpose of this paper to review what is known about the impact of managed care on the outcomes of care for persons with mental illness and to suggest issues that should be given priority in future research. In one sense this is relatively easy to accomplish. The current literature on mental illness treatment and outcomes in managed care is limited in scope and depth, although it is expanding (Mechanic et al., 1995; Wells et al., 1995). This suggests that much more needs to be known, but provides little insight into the relative importance of different areas of mental health outcomes research and evaluation.

The discussion of information needs and priorities for research uses the quality-of-care paradigm of structure, process, and outcome. The incentives inherent in managed care capitation payment systems versus traditional indemnity fee-for-service (FFS) payment systems are explored to focus on a series of hypotheses regarding differences in structure, process, and outcomes. In this context, the existing research evidence and its limitations are discussed. This leads into a discus-



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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH C Consumer Outcomes and Managed Behavioral Health Care: Research Priorities Donald M. Steinwachs Center for Research on Services for Severe Mental Illness, Health Services Research and Development Center, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health The growth in managed care and managed behavioral health care, with their incentives to reduce costs, has raised concerns that active management of utilization may lead to poorer quality of care and to poorer outcomes for persons with mental illness. The current evidence suggests that substantial cost savings are being achieved by managed care, but with patient outcomes that are no worse than those in the fee-for-service system (Iglehart, 1996). However, many concerns are being raised about the potential for adverse consequences as managed behavioral health care expands to cover more seriously ill and disabled populations (Mechanic et al., 1995). It is the purpose of this paper to review what is known about the impact of managed care on the outcomes of care for persons with mental illness and to suggest issues that should be given priority in future research. In one sense this is relatively easy to accomplish. The current literature on mental illness treatment and outcomes in managed care is limited in scope and depth, although it is expanding (Mechanic et al., 1995; Wells et al., 1995). This suggests that much more needs to be known, but provides little insight into the relative importance of different areas of mental health outcomes research and evaluation. The discussion of information needs and priorities for research uses the quality-of-care paradigm of structure, process, and outcome. The incentives inherent in managed care capitation payment systems versus traditional indemnity fee-for-service (FFS) payment systems are explored to focus on a series of hypotheses regarding differences in structure, process, and outcomes. In this context, the existing research evidence and its limitations are discussed. This leads into a discus-

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH sion of the author's view of research priorities and strategies for filling the current gaps in knowledge. BACKGROUND The growth in the 1990s of managed health care has exceeded all previous expectations. Federal policy actively promoted capitated and comprehensive health care for the first time with the passage of the 1973 Health Maintenance Organization (HMO) Act. The growth in HMO enrollment in the 1970s and 1980s was substantial, but HMOs remained a source of health care for a small proportion of Americans (Luft, 1987). During the 1980s new forms of managed care emerged, including the preferred provider organization (PPO). This added to the penetration of managed care and gave it recognition as a significant and growing sector of the health care system. The failure of health care reform in 1994-1995 did more to accelerate the implementation of managed care than any federal initiative had previously achieved. This should not be surprising. Over the previous 10 years, elements of managed care had been progressively adopted by major payers to control the growth in utilization and costs. These elements include precertification of elective hospital admissions, concurrent review of length of stay or use of per-case payment, substitution of ambulatory surgery and diagnostic testing for inpatient services when appropriate, and other controls including limiting the use of emergency rooms, establishment of drug formularies, and organizational control over the selection of the practitioners included in networks or group practices (Payne, 1987; Weiner and de Lissovoy, 1993). The literature suggests that these actions can individually and collectively reduce health care costs below the levels found in FFS practice and even more so for mental health care (Frank et al., 1995). The utilization control strategies used in managed medical care have been applied to mental health and substance abuse services (Mechanic et al., 1995). Among an estimated 185.7 million people with private insurance in 1994, 106.6 million were enrolled in plans that offered some form of managed behavioral health care (Iglehart, 1996). One difference, however, is that the tradition of HMO and indemnity insurance coverage for mental illnesses has not been comparable to the coverage for somatic health problems. Historically, the treatment of chronic mental illness has not been covered by HMOs, and indemnity insurance has restricted mental health benefits such that persons with chronic and disabling illnesses would be likely to use services in excess of the available coverage (McFarland, 1994). The reasons for this distinction between mental and somatic illnesses were numerous, including uncertainty that mental illnesses could be cured or medically managed and the role of the states and the public sector as the last provider of mental health services, particularly for persons with severe and persistent mental illnesses (Grob, 1991). Also, significant stigma has been associated with mental illness, which has tended to suppress the demand for ser-

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH vices and for expanding coverage. Another reason for limiting coverage was to limit costs, which became a major topic of debate during health care reform deliberations (Arons et al., 1994; Frank et al., 1992). Significant changes that have occurred over the past two decades are likely to lead to greater comparability in coverage between mental and somatic disorders. The biological basis of many mental illnesses has been established, and the efficacies of drug and other treatments have been demonstrated for many disorders. Even so, the stigma associated with mental illness continues, but it appears that this may be slowly changing too. Laws to guarantee parity of benefits for mental illness have been passed in several states and were considered recently by the U.S. Congress. Parity legislation can be expected to shift more of the cost burden for the treatment of severe and disabling mental illness from the public sector to the private health insurance system. How this will affect persons with severe mental illness is uncertain. Many of these individuals are deprived of the ability to work and gain income, leaving them in poverty and reliant on welfare and publicly supported health insurance, under Medicare or Medicaid. However, it is clear that managed care will be involved. One of the more recent trends has been the movement of Medicaid programs to managed care. By June 1994, 7.8 million Medicaid beneficiaries were enrolled in some form of managed care, double the number in the previous year (Essock and Goldman, 1995; Iglehart, 1996). SPECIALIZED MANAGED CARE: MANAGED BEHAVIORAL HEALTH CARE As managed care grew in the 1980s and grew at an accelerated rate in the 1990s, specialized managed behavioral health care networks emerged (England and Vaccaro, 1991). Managed behavioral health care companies sell managed care services, ranging from utilization review to accepting capitated risk as a provider of specialty mental health services. A new terminology emerged to describe carve-outs and carve-ins as means of integrating managed behavioral health care services into a network of managed health care services. Managed care organizations are created through a series of contractual arrangements with primary care providers, specialty providers, hospitals, utilization managers, and behavioral health firms (Gold et al., 1995a). This is quite different from the HMO concept embodied in the 1973 HMO Act that stimulated the growth of group practice and independent practice association HMOs. The newer forms of managed care include PPOs, physician-hospital organizations, and point-of-service plans. Although there are growing numbers of variations on the HMO concept, they share most of the elements common to HMOs: they offer a limited choice of practitioners, they make efforts to control the use of high-cost services and to substitute lower-cost services when appropriate, they provide comprehensive coverage, and they require low out-of-pocket payments for services.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH MANAGING MENTAL HEALTH CARE The need for information on managed care is elevated by policy concerns at the state and federal levels. Questions have been raised regarding how treatment and patterns of care received under the managed behavioral health care system differ from those received under the indemnity insurance system. To the extent that patterns of care differ, how is this affecting patient outcomes? The previous discussion suggests a range of hypotheses that derive from financial incentives and organizational differences between the managed care and traditional indemnity insurance systems. These hypotheses are organized around the quality-of-care framework presented by Donabedian (1993) that organizes quality into three areas: structure, process of care, and outcomes of care. Structure and Access to Care Choice of Practitioner In concept, indemnity insurance has made it possible to go to any practitioner in the community. This is largely true for well-insured, middle-class Americans. However, for those with more limited incomes, practitioners who do not accept Medicare and Medicaid payments or who bill their patients for the amounts that are not covered by Medicare or Medicaid may have out-of-pocket costs so high that many people cannot afford them (Berk et al., 1995). For persons covered under medical assistance programs (Medicaid), the level of payment to participating practitioners may be so low that many practitioners will not accept patients with this coverage. Yet, most Americans continue to perceive that indemnity coverage makes it possible to choose any practitioner. In contrast, managed care offers the patient a defined panel of providers, with the size of the panel varying from few to most community providers. In POS and PPO managed care plans, any practitioner can be chosen, but the cost of going outside of the preferred panel is a substantial deductible and coinsurance comparable to those under indemnity coverage. On the basis of these characteristics, the following is hypothesized: Hypothesis 1A: Managed care leads to the concentration of patient services among a more limited set of providers than occurs under indemnity insured care. It is clear that the managed care system uses organizational and financial incentives to limit the choice of providers (Gold et al., 1995a), but the literature does not appear to include any studies evaluating the impact of managed care on

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH the number and type of providers seen for specific health problems, including mental illness. Access and Availability of Services Another aspect of the structure of health care concerns the availability of services. In each community there are limits on the availability of health services, but additional limits that are not present under indemnity insurance plans are likely to be imposed by managed care plans. Even though managed care plans control the availability of physician services, they provide 24-hour access and have financial incentives to provide accessible urgent care during off hours instead of having enrollees go to hospital emergency rooms (Gold et al., 1995a). A study of Medicare beneficiaries found them to be more satisfied with waiting times for an appointment under the managed care system than under the FFS system (Rossiter et al., 1989); however, these results were not specific to mental health care services. This leads to the following hypothesis: Hypothesis 1B: Delays in receiving nonurgent care will be less in the managed care system than in the indemnity covered care system; urgent care will be more accessible in the managed care system. Access and Unmet Need Important differences exist between indemnity insurance and managed care plans in the use of coverage limits and out-of-pocket payments to control utilization and costs. Indemnity insurance coverage has relied on limiting coverage and imposing significant deductibles and coinsurance to reduce utilization and costs. The effects of deductibles and coinsurance were evaluated in the RAND Corporation's Health Insurance Experiment in the 1970s (Manning et al., 1986). The study found that persons were less likely to seek treatment when faced with significant out-of-pocket payments, but when treatment was sought, the pattern of treatment did not substantially differ by level of deductible or coinsurance (Keeler and Rolph, 1988; Keeler et al., 1986). This was found for both mental and somatic disorders. In contrast, HMOs and other managed care organizations offer comprehensive coverage (except for specialty mental health services) and impose few or no deductibles and small or no copayments. When there are higher copayments for mental health care, these have comparable effects on reducing utilization (Simon et al., 1994). With the implementation of a managed behavioral health care carve-

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH out in the Massachusetts Medicaid program in 1992, the results from the first year found a higher proportion of enrollees receiving mental health care under managed care (Stroup and Dorwart, 1995). Here changes in access would not have been related to out-of-pocket costs but may have involved changes in other organizational and provider characteristics. In McFarland's (1994) review of previous research on HMO services provided for mental illness, he found a “pattern in which HMO members are as likely as or more likely than non-HMO members to visit a mental health provider but tend to have fewer contacts with that provider after the initial visit.” The net effect of lower access barriers in managed care should be greater accessibility of services for those with a need for care. This leads to the following hypothesis: Hypothesis 1C: Unmet need for care will be higher under indemnity coverage than under managed care. Provider Participation One of the complexities in evaluating the impact of managed care, and particularly managed mental health care, is the range and complexity of organizational and financial arrangements (Gold et al., 1995b). Individual practitioners may be paid on a fee-for-service basis but at a reduced rate or may share risk through a full or partial capitation. Since a practitioner sees patients covered under different insurers, the financial incentives may vary substantially from one patient to the next. Thus, practitioners would be expected to respond to incentives in a way that would maximize their practice and income preferences. Little is known regarding how practitioners make choices regarding joining a managed care network and how they respond to a complex array of incentives arrangements when they are part of multiple managed care organizations. At the same time, managed care organizations make choices regarding which practitioners to ask to participate in their network. This choice may involve the use of practitioner profiles (Salem-Schatz et al., 1994) that identify higher-cost practitioners and that exclude them from the network. Initially, efforts to market managed care organizations in new geographic areas may give priority to market penetration and may include as many participating practitioners as possible. Over time, however, the managed care organization may wish to concentrate its enrollees among a more limited set of practitioners whose practices are consistent with managed care organization expectations. These dynamics are complex and lead to the following hypothesis:

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Hypothesis 1D: Practitioner participation in managed care organization networks is jointly determined by practitioner preferences, practice characteristics, and managed care organization market strategies. The structure of managed care organizations is evolving and changing as organizations seek to learn through experience what works and how to improve on existing organizational and financial incentives. As a result, there are unusual opportunities for research, but some opportunities may be time-limited and may require access to privileged management information. Process of Care Screening and Treatment Detection and Diagnosis The process of care may involve screening, diagnosis, treatment, follow-up, and maintenance care, plus rehabilitation in some instances. Under the managed care system some would argue that the financial incentive is not to diagnose new problems because this adds to costs. However, the mental health research on cost offsets indicates that failure to diagnose and treat mental and emotional problems does not prevent future utilization and costs, and may make utilization more costly (Fiedler, 1989). One example is Northern California Kaiser Permanente Medical Care Program, which has reported savings of medical costs by upgrading its behavioral health care benefit (Iglehart, 1996). In contrast, the financial incentives under indemnity coverage are to provide more services that might increase rates of detection and follow-up care. The Medical Outcomes Study (MOS) of the diagnosis, treatment, and outcomes of one mental illness, depression, found somewhat lower rates of detection under the prepaid care system, primarily related to the greater use of primary care practitioners, who have substantially lower detection rates than mental health specialists (Wells, 1989; Wells and Sturm, 1995). However, the Massachusetts Medicaid managed behavioral health care carve-out appears to have led to higher rates of specialty care, possibly associated with higher rates of detection and referral (Stroup and Dorwart, 1995). Since there are complex incentives arrangements affecting care-seeking and mental illness recognition, it is uncertain which direction a hypothesis should be stated; however, the following hypothesis is provided:

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Hypothesis 2A: The probability of detection and diagnosis of mental and emotional problems will be the same under the managed care system as under the indemnity insurance system. Use of Hospitals and Specialty Care Although there is some uncertainty regarding the direction of potential differences in detection and diagnosis rates, there are clear incentives for managed care plans to provide less intensive services for the treatment of mental and emotional problems, as reflected by the lower level of use of inpatient psychiatric services. This usually involves a process for preadmission certification. Wickizer et al. (1996) found little reduction (less than 2 percent) in admissions. In the Massachusetts Medicaid managed behavioral health care carve-out, there was a 22 percent reduction in overall mental health costs in the first year and a 30 percent reduction in inpatient psychiatric services (Stroup and Dorwart, 1995). The structure of incentives leads to the following hypothesis: Hypothesis 2B: The probability of hospitalization for a mental illness will be lower under the managed care system than under the indemnity insurance system, as will the probability of referral to a mental health specialist, except when there are fiscal incentives for primary care providers to refer a patient to mental health specialty providers. Duration of Treatment Another way to control the cost of treatment is to control the duration of treatment. Under the indemnity insurance system, the incentive is to continue to treat mental illness until the coverage limits are reached or the patient decides that no more treatment is desired. Under the managed behavioral health care system, there is active utilization review to assess the need for continuing services in inpatient and outpatient settings. In inpatient settings, one recent study found precertification and continuing stay review led to 16.8 days of stay approved out of 23.5 days requested (Wickizer et al., 1996). In a study of admissions for affective disorders, Frank and Brookmeyer (1995) found both short-term and longer-term savings from preadmission certification programs that came from fewer admissions, even though readmission rates were somewhat higher, and shorter lengths of stay. In the Massachusetts Medicaid managed behavioral health care carve-out there were reductions in length of stay of from 9.7 to 8.7 days in the first

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH year, and for persons with severe mental illness, the reductions were from 22.5 to 17.8 days (Stroup and Dorwart, 1995). In an evaluation of PPOs, Wells et al. (1992) found lower rates of ambulatory services use in the PPO than in the indemnity insurance system, but access was comparable. As a result, it would be expected that: Hypothesis 2C: The duration of treatment episodes under the managed care system will be shorter than the duration of treatment episodes under the indemnity insurance system. Prescription Patterns There does not appear to be much research on the patterns of medication use for mental illness in managed care settings. In a study of general prescription practices, Weiner et al. (1991) found that practitioners at managed care plans were more likely to use generic drugs than practitioners under the indemnity insurance system, but that practitioners under both systems were equally likely to use newer and frequently high-cost medications. The MOS found that the HMO patients were less likely to receive the clinically recommended dose of the prescribed anti-depressant than patients receiving care under the indemnity insurance system, but the difference was largely ascribed to the greater use of primary care physicians in the HMO compared with the use of greater numbers of specialists in the indemnity insurance system (Wells and Sturm, 1995). It is not known to what extent managed care organizations have responded to this finding and have encouraged the use of the appropriate dosage that has been found to contribute to better outcomes. The differences that are likely to persist will be those that relate to controlling costs, leading to the following hypothesis: Hypothesis 2D: Treatment with medications will be the same between the managed care and indemnity insurance systems, but practitioners at managed care plans will be more likely to use generic substitutes and other lower-cost alternatives. This discussion has reviewed some of the findings related to differences in the use of services between managed care plans and the indemnity insurance system. These differences reflect the differences in financial incentives between capitation and fee-for-service payment plans. In general, managed care plans use less intensive and lower-cost services, with uncertain implications for the quality of care.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Quality of Care Quality-of-care studies among HMOs in the 1950s to the 1970s found that the prepaid group practice and staff model HMOs provided care of equal or higher quality compared with that provided by other community providers (Luft, 1987; McFarland, 1994). Few studies have been conducted since the rapid growth of managed care organizations. Currently, the Schizophrenia and Depression Patient Outcome Research Team projects are examining quality-of-care issues and the impact of quality of care on patient outcomes. The MOS found process of care differences, with lower rates of diagnosis and appropriate treatment in the HMO, but this was largely explained by a greater reliance placed on primary care physicians than physicians in the FFS practice setting, with greater reliance on mental health specialists (Wells and Sturm, 1995). Under different carve-in and carve-out arrangements, there may be substantial variations in the use of specialty services among managed care organizations. As a result of these uncertainties, the following hypothesis is suggested: Hypothesis 2E: Adherence to quality-of-care criteria for the diagnosis and treatment of mental illness will be equal under the managed care and indemnity insurance systems, but it will be greater when mental specialists are providing care. Outcomes of Care: Clinical, Health Status, Satisfaction, and Costs It is easier to develop hypotheses regarding access to services and patterns of use than to hypothesize the presence and direction of differences in outcome. The hypothesized differences in structure and treatment process discussed above are unlikely to equally affect outcomes. Those likely to have greater impacts are the following: Better access to primary care and preventive services for individuals in managed care settings than for individuals with indemnity insurance coverage may reduce unmet need for services. Reduced access to specialty services for individuals in managed care settings may lead to less adequate treatment and poorer outcomes than for individuals who are covered by indemnity insurance. The provision of less intensive services of shorter duration in managed care settings than in settings covered by indemnity insurance may lead to equal or poorer outcomes. There is some evidence to support the contribution of specialty care to better

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH mental health outcomes, as found in the MOS for depression (Wells and Sturm, 1995). The receipt of specialty care was less likely in HMOs. The MOS examination of depression treatment and outcomes across fee-for-service and HMO practice settings is unique (Wells, 1989). Although one may want to draw conclusions regarding the impact of the managed care system on mental illness treatment and outcomes, it is important to remember that HMOs are not representative of the range of today's managed care plans and that most fee-for-service practitioners are now practitioners for one or more different managed care plans (Gold et al., 1995b). Studies of the impact of capitation payment in both public and private systems have been conducted (Lurie et al., 1992), with mixed or uncertain findings regarding outcomes. The traditional indemnity coverage is disappearing, with Medicare beneficiaries and a small proportion of privately insured individuals remaining. Thus, the available evidence is stronger for differences in outcomes between specialists and generalist practitioners than between managed care and other settings covered by indemnity insurance. Hypothesis 3A: Clinical status, health status, and satisfaction outcomes will be better for those receiving specialty care, no matter whether this is under the managed care or the indemnity insurance system, but the costs of specialty care will be higher than primary care. The expectations that access to primary medical care is better in managed care organizations than in settings covered by indemnity insurance, plus the MOS findings comparing HMO and FFS practice settings, lead to the following hypothesis: Hypothesis 3B: Population-based outcomes will be better in the managed care setting than in settings covered by indemnity insurance; greater access to primary care services and utilization of preventive and screening services will lead to lower levels of unmet need, although more limited access to specialty services in the managed care setting will contribute to poorer outcomes among those treated. Unfortunately, there do not appear to be any studies that can support or refute this hypothesis. This requires the linkage of epidemiological studies comparing the need for care with utilization data and outcomes assessment. The methodology might build on the work of Shapiro et al. (1985), who linked indicators of

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH comes and effectiveness research is one means for identifying opportunities for improvement in services by providing new insights into the critical managed care question: how can services be organized and provided to defined populations to maintain and improve health outcomes at a reasonable cost? To ensure the relevance and application into practice of the findings of outcomes research, a close alignment between outcomes research priorities and the issues facing managed care will be needed. RESEARCH PRIORITIES The challenge of setting priorities in an area of health care that is rapidly changing and that is relatively poorly understood by researchers is significant. Research has traditionally required long-term investments to produce information that can be used by policymakers, practitioners, regulators, consumers, and other users. Maximization of the value of a long-term investment strategy, and at the same time responsiveness to more immediate demands for information, suggest the need for an integrated strategy in which key elements of managed care are characterized and efforts are made to stimulate researchers to examine these elements in a variety of settings. The long-term research question to be addressed is the following: how can health and mental health care be better managed (organized, financed, and delivered) to achieve the full range of outcomes desired by payers, practitioners, consumers, and the public? In a rapidly changing environment, priority may be given to using research to assess the adverse risks of change on quality of care and patient outcomes. This is an important priority and should be pursued. At the same time, a changing environment opens opportunities for innovation that may not be found at other times. Now is a time to encourage researchers to conceptualize and evaluate innovative strategies for providing health care that break from tradition. Health services researchers should be asking the question, “If American health care were being redesigned from the bottom up, what type of health care system should be developed to meet the needs of persons with behavioral health problems?” This might involve a very different mix of health care practitioners and might redefine the roles of patients, families, and practitioners. In the following discussion a simple framework for examining mental health care management and outcomes will be used to suggest research topics and priorities related to patient outcomes. A caution is offered, however, in listing specific issues: the attention tends to be focused on system components and not the overall system structure. Both need to be addressed in outcomes research. Assumptions In an effort to focus on specific priorities, assumptions concerning care for a mental illness and the overall care management process will be made. The first

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE C.1 Managing Care: Elements of the Process Access to care: Consumer, family, and practitioner roles Recognition of problem Recognition of need for care Decision to seek/provide care Barriers to receiving/providing care Diagnosis and treatment Diagnostic criteria Practitioner—primary care or specialty care (physician or nonphysician) Treatment guidelines Follow-up arrangements to ensure continuity and maintenance Utilization controls Financial incentives to practitioner and patient Limits of coverage Role of family, employer, and self-help groups Rehabilitation Assessment of need for services Limits of coverage Cost and utilization controls Follow-up arrangements Role of family, employer, and self-help groups assumption is that mental illness is frequently recurrent or chronic in nature, and its care should be approached from a perspective of long-term management and the prevention of a recurrence. The importance of this assumption is that it suggests that the patient and family need to be full participants in the management of the care and in decision-making processes, or the goals of preventing recurrences and maximizing long-term outcomes are less likely to be achieved. The second assumption is that managing care involves managing access; diagnosis, treatment, and maintenance; and rehabilitative care. In Table C.1, there is an effort to identify some of the elements used in managing these three stages in the care process. These will be discussed more fully as specific priority recommendations are made. A third assumption is that research on the care of persons with the greatest needs should be given higher priority, as should research on preventing the worst outcomes of mental illness. By using these assumptions and the elements in Table C.1, the potential for managed care to improve the delivery of mental health care will be examined to identify priority topics for research.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Population-Based Mental Health Outcomes: Opportunities for Improvement Under the managed care system, there is a need to address both population-and patient-based outcomes. Population- and patient-based outcomes have not been addressed in the indemnity insurance system. Three observations from the literature regarding mental illness care provide the basis for discussing opportunities for improvements of population-based outcomes. First, mental illnesses tend to go undiagnosed and untreated, leading to high levels of unmet needs for care (Shapiro et al., 1985). These tend to be higher than those for somatic disorders. When diagnosed, mental illnesses are frequently inadequately or inappropriately treated, as is true of many somatic health problems. Even when treatment is initiated, many patients fail to continue treatment, fail to complete referrals, and are lost to follow-up, maintenance, and rehabilitative care. This, too, is true of the care for many chronic somatic disorders. Taken together, population-based outcomes are driven by the combination of unmet needs for care, inadequately or inappropriately met needs when services are received, and a lack of effective long-term maintenance strategies to maximize long-term outcomes. For example, in the early days of the National Heart, Lung, and Blood Institute National High Blood Pressure Education Program, it was noted that 50 percent of those with high blood pressure knew it, 50 percent of those who knew it were receiving care for high blood pressure, and 50 percent of those who were receiving care had their blood pressures under adequate control. From a population-based perspective, 12.5 percent were achieving the desired clinical outcome. This low rate of effective care for a population with a specific health problem may be quite similar to the current situation in the treatment of behavioral health problems. Efficacious treatments are available for most mental illnesses. The challenge is to bring those who can benefit from treatment under effective and ongoing clinical management. How can research on managed care accelerate the development and implementation of effective strategies for addressing these three major determinants of poorer health outcomes? The following are suggested elements in a strategy for achieving this goal. In each of these elements, there is the issue of the cost of care and the need to identify efficient service strategies to achieve good outcomes. Structure of Managed Care The observation that managed care is rapidly changing and evolving is taken as a truism. For this reason, the study of managed care as an entity is not as relevant as it was in the previous two decades when HMOs were relatively stable and were compared with FFS medicine. Hence, it becomes important to understand the impacts of the specific mechanisms used to manage care and how combinations of these mechanisms affect access, processes of care, and outcomes. As yet,

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH there is little research on specific mechanisms beyond capitation payment (Mechanic et al., 1995) and the need for precertification for inpatient services (Frank and Brookmeyer, 1995). Another reason for focusing research on managed care mechanisms and their impacts on outcomes of care is the increasing difficulty of identifying opportunities to compare managed care with “unmanaged ” or settings covered by indemnity insurance without some managed care features. The current research opportunities are evolving toward comparisons of populations that receive care under different managed care mechanisms that may be applied with varying degrees of rigor and consistency. An example of managing care for persons with severe and disabling mental illness is the Program for Assertive Community Treatment (PACT). This has been evaluated over the past two decades and has demonstrated positive outcomes at a cost comparable to or less than that for long-term hospitalization (Stein and Test, 1985). Recent work is showing a relationship of outcomes to the degree of fidelity to the PACT model (McGrew et al., 1994). Similarly, research is needed to measure the relationship between managed behavioral health care strategies and outcomes. Problem Recognition Population-based health care needs efficient strategies for recognizing behavioral health problems. Multiple foci should be explored, including enhancing practitioners' abilities to recognize behavioral health problems and provide them with incentives to diagnose such problems, examining the role of the employer (e.g., employee assistance programs), and examining the role of the family and consumer. However, recognition of a behavioral health problem is not sufficient. Research is needed on effective strategies to decrease the stigma associated with behavioral health problems and to make consumers and families more willing to enter care. This could involve research on strategies for public education and opportunities for consumers to assess their own problems by having access to screening instruments and referral guidelines. The question is how can the unmet needs of enrolled populations be more effectively addressed at a reasonable cost? Entering the Care Process As the managed behavioral health care system grows, many questions are being raised. Are there new models for engaging consumers with behavioral health problems in the care process? What is the role of the primary health care system, in which the majority of patients are treated for behavioral health problems? How can outcomes measurement strategies encompass both those who enter care and those who do not? One of the major concerns is whether it will be known if the managed care system is reducing the number of individuals with unmet needs. An

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH example of a research and demonstration strategy is being implemented by the Mental Health Outcomes Roundtable. It is testing the feasibility of using complementary strategies to measure population- and patient-based outcomes using a population survey and patient questionnaires (Flynn and Steinwachs, 1995). One concern is whether or not there are measurement tools and strategies that can do this at a reasonable cost. The National Committee for Quality Assurance's (NCQA's) Health Plan Employer Data and Information Set (HEDIS) report cards have pushed managed care organizations to be concerned with population-based measures of access for preventive care; comparable measures are needed for behavioral health care. Choice of Provider: Cost and Effectiveness As indicated above, the PACT model of team care has been the subject of extensive research on cost and effectiveness. As the managed behavioral health care system attempts to put together provider panels and teams to care for the full spectrum of mental illness and substance abuse problems, there will be questions regarding what makes a cost-effective team, when a team approach is needed, and how mental health professionals should be trained in the future to participate in managed care. In many ways very little is known about staffing and organizational options and how they contribute to consumer outcomes and costs. This issue also touches on the structure of medical practice (e.g., prescription privileges), self-care and consumer-organized care (e.g., clubhouses), and the roles of the different professional groups now providing mental health care. There appears to be little research on how to put together the managed care team for population-based management, and this is critically important to the future of managed care. Treatment Strategy Mental health is beginning to adopt practice guidelines and promote quality-of-care research that is comparable to research on medical and surgical conditions. The general impression is that mental health has lagged behind medicine in efforts to move toward explicit quality-of-care criteria (guidelines). Yet, the efficacies of treatments for mental illnesses are in many ways better established than the efficacies of treatments for many medical problems (NIMH, 1993). Using the results of efficacy studies and effectiveness research, the process of developing quality-of-care criteria needs to be accelerated if the information needed to assess quality of treatment under any and all forms of managed care is to be available. Mental health quality-of-care research needs to recognize the special roles of consumers and families in the care of individuals with chronic and recurring illnesses. There are effective ways to involve the family in the care process to improve outcomes, and these should be part of high-quality care (Lehman, 1995). Individuals may not receive high-quality care for many reasons. Failures may

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH occur in the system, the practitioner may not diagnose the illness or prescribe medications consistent with quality standards, and the patient may not adhere to the practitioner's directions. In research, special attention also needs to be given to the consumer's incentives to be a full participant in the care process, not just the practitioner 's incentives to diagnose and treat the consumer effectively. High proportions of patients are reported to drop out of treatment and to stop taking medications. It appears that relatively little is known about how to engage consumers and families in the long-term process of chronic disease management. Essentially, research into ways to support consumers and families in integrating the care process into their daily lives is needed. Targeting High-Risk, High-Cost Patients The success of many health care interventions lies in the capacity to efficiently identify high-risk cases and intervene effectively. It is not clear that there has been sufficient progress in developing useful criteria for identifying high-risk or high-cost patients that can be used by managed care plans to target individuals and groups for outreach and active case management. Complicating the problem is the frequent observation that high-risk and high-cost patients have multiple morbidities (comorbidity) and may require specially integrated treatment systems. Current research on cost-effective models for integrated treatment of comorbidities appears to be lacking. If cost-effective strategies to manage high-cost patients are not tested and evaluated, the incentives of managed care may lead to minimal maintenance strategies that attempt to contain costs and that may not maximize outcomes. Priorities Among Elements of Managed Care Other elements in care management will need to be examined critically if there is to be a truly managed health care system that respects the consumer and family roles and achieves goals related to outcomes of care and costs. A potentially effective strategy for developing a full research agenda on managed care outcomes would be to bring together all the stakeholders in managed behavioral health care, including consumers and families, payers, regulators, practitioners, policymakers, and researchers. The objective would be to define the long list of researchable issues and to identify priorities. The product could be a national plan that could serve the very useful role that the NIMH National Plan to Improve Care for Persons with Severe and Persistent Mental Illness did in the early 1990s (NIMH, 1990). The purpose of the plan would be to focus research resources and researchers on key issues in the rapidly changing system.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH STRATEGIES FOR FILLING THE GAPS IN KNOWLEDGE Substantial gaps in knowledge related to behavioral health care exist, and the system is in a process of change that does not allow the leisure of relying solely on long-term research strategies if the direction of change is to be influenced through research. This suggests that a mix of strategies may be needed if current demands for better information are to be met and if the long-term needs for information to improve treatment and service systems are to be ensured. Secondary Data Strategies, Health Statistics, and Report Cards One of the highest priorities for research should be the development and testing of measures of population-based behavioral health care performance that could be incorporated into report cards. HEDIS and NCQA have begun the process, but measures of mental health care are less well developed than some of those for preventive services and other chronic diseases (e.g., diabetes). A range of research issues is involved, including quality-of-care measurement (i.e., what care predicts good outcomes), population-oriented as well as patient-oriented measures, and valid and reliable strategies for obtaining measures at reasonable costs. Work by CMHS has provided measures of satisfaction, and the Mental Health Outcomes Roundtable is testing disease-specific modules for depression and schizophrenia plus population-based survey strategies (Flynn and Steinwachs, 1995). The Managed Behavioral Health Association is developing and testing its report card. This work needs to be accelerated and substantially expanded. It should include both public and private initiatives. Notable is the absence from almost all report cards of outcomes measures except in the area of satisfaction. This limitation of current report cards urgently needs to be addressed. Attention needs to be given to national survey strategies in the new managed care world. The traditional tracking of specialty practitioners and services by CMHS needs to be reconsidered, and ways to incorporate measures of quality and consumer outcomes need to be examined. This may be the only way to track trends over time and to produce timely information on changes in the overall system. Strategies for Outcomes Management Systems Increasingly, managed care organizations are attempting to track outcomes and link this information to costs (Burlingame et al., 1995). As early experience suggests (Steinwachs et al., 1994), the routine collection of outcomes information is not simple, and the interpretation of this information for quality improvement is frequently uncertain and can be a complex task. This is an excellent area in which the use of considering multisite outcomes tracking and quality improvement efforts

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH should be considered. No single organization may be able to invest the time and resources needed to adapt research instruments to everyday use and the analytic expertise to analyze and interpret the results. Furthermore, no single organization can know how well it is doing compared with the performance of other practitioners (e.g., benchmarking). The model of outcomes data collection being developed by the Managed Health Care Association Consortium on Outcomes Management, the Mental Health Outcomes Roundtable, and the Foundation for Accountability needs to be examined critically and could become part of a national research demonstration agenda. The goal would be quality improvement, and the products would include report card strategies for ensuring accountability. Focusing on Mechanisms for Managing Care The focus on research into the impact of mechanisms for managing care on consumer outcomes will require new partnerships between researchers and managed care organizations. There has been limited experience in developing these partnerships from either the researcher or the managed care perspective. One way to accelerate this process may be to address two fundamental concerns. First, well-developed models (including model contracts) that protect the interests of both the researcher and the managed care organization are needed. Second, funding sources need to be available to promote joint research, much as there has been NIMH funding to promote mental health research in the public sector. A key factor toward success is likely to be the choice of research topics that can bring together the interests of the two parties and that do not involve high levels of risk for either party. Research on the long-term role of consumers and their families in the successful management of care is also going to be important and may involve working with family and consumer groups, since people switch insurance and managed care plans. Collaborations with consumer and family groups could also benefit from similar investments in developing models for productive relationships and providing targeted support. Research and Demonstrations on Improved Systems for Mental Health Care Managed care is making changes, some of which are considered radical, but most are on the margins of current medical practice. One potential drawback of incremental change is that it may not lead to real innovation in treatment and improvement in consumer outcomes. This can result from a series of incremental changes that do not lead to a well-defined vision of what the future health care system should be. There needs to be an effort to solicit the best thinking of researchers and the managed care system regarding innovative models for managed

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH behavioral health care. These could be funded under research and demonstration authority if they were related to the Medicare or Medicaid programs. The key is to attempt to move the research agenda to address issues that are in front of where managed care is making its changes today. Otherwise, the danger is that researchers will too easily focus their energies on evaluating the changes introduced by managed care and not think creatively about what managed care should be. Research and demonstration initiatives should target innovative models that break from tradition by testing alternative ways to manage care, provide services, and monitor outcomes. SUMMARY AND CONCLUSIONS The growth of managed behavioral health care is making this one of the most interesting times in U.S. health care, yet it is placing many consumers at considerable risk when existing care arrangements are disrupted. Without systems for measuring quality of care and patient outcomes, the documentation of the impact of change may be no more than a series of anecdotal stories. There is an urgent need to develop and improve measurement tools (quality of care, access, and outcomes) and to refine research designs that can make it possible to monitor and evaluate the end results of health care, that is, consumers' health outcomes. The proposed research focus on how to manage care effectively and efficiently is a long-term agenda. An evaluation of each new type of managed care organization would appear to be of limited value since these organizations usually change consequentially by the time the results become available. There is value in focusing on the specific mechanisms used to manage care and their consequences for consumer outcomes. The promise of managed care needs to be more clearly conceptualized than it has been. The research agenda needs to examine critically mechanisms and strategies for achieving positive outcomes for consumers through a population-based focus on health and mental health care. Although the challenges for outcomes research are great, the potential to improve consumer health outcomes and control costs will only succeed if there is an ever growing base of information that links the processes of behavioral health care to the outcomes valued by consumers. REFERENCES Arons BS, Frank RG, Goldman HH, McGuire TG, Stephens S. 1994. Mental health and substance abuse coverage under health reform. Health Affairs 13(1):192-205, Spring. Berk ML, Schur CL, Cantor JC. 1995. Ability to obtain health care: Recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey. Health Affairs 14(3):139-146, Fall. Burlingame GM, Lambert MJ, Reisinger CW, Neff WM, Mosier J. 1995. Pragmatics of tracking mental health outcomes in a managed care setting . Journal of Mental Health Administration 22(3):226-236.

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