AMBHA Five Core Approaches


1. Services are provided through integrated and coordinated delivery systems.
	The health plan management agent develops and manages coordinated care processes. Many health professionals working in solo practice isolation are not trained nor are they willing to coordinate their services to treat a patient's entire health situation.
2. Health plans, their management agents, and their providers must publicly document their accountability for positive clinical outcomes and consumer satisfaction.
	The development and operation of management information systems using nationally developed standardized performance measures is the method to publicly document accountability. Many professionals state that graduate education, a state license, and any willing provider solo practice fee-for-service where the patient can change provider at any time is sufficient accountability. Management of care argues that accountability entails documented performance. AMBHA advocates that any entity which claims to manage care - regardless of ownership or structure (profit, not-for-profit, governmental entity, full-service HMO, managed behavioral healthcare specialty, provider-sponsored organization) - must meet the same national documented accountability standards. The issue of confidentiality greatly complicates this drive for public accountability.
3. Managed behavioral healthcare results in the expansion of services but also in the substitution of services.
	Experiences in both the private and public sectors are the same - the number of people seeking services and provided services increases after the introduction of managed care.Inpatient hospitalizations and solo practice psychotherapy decline. Psychiatric rehabilitation, day treatment, consumer-run/peer support, residential treatment, crisis programs, and the integration/coordination of medication and medication management with day services increases. Hospitals and solo practice psychotherapists complain about the decline in the volume of services they deliver. Hospital admissions and hospital length-of-stay both decline.
4. Managed care plans are obligated by payers to constrain costs.
	Experiences with managed behavioral healthcare - both private and public sectors - have resulted in cost containment. These are insisted upon by payers. Many payers have mandated use of capitation to limit costs. Manage care organizations use managed networks of providers with discounted fee structures to help restrain costs. AMBHA uses a phrase - cost is the driver but delivery is the key. We acknowledge that payers - who are using competitive bidding - insist on cost containment but also expect service delivery which meets performance standards. Professionals do not like managed networks and discouunted fees which payers are insisting upon.
5. Medical necessity is used for both access and service continuation.
	Prior to managed care, private plans typically provided 30 days of inpatient hospitalization and 20 visits of psychotherapy a year. Insurance companies merely paid up to the limit. If a person had a serious mental illness they were then transferred to the public mental health system where state hospitals and community clinics with waiting lists dominated. Thus services were rationed within a two-class system. Some public mental health systems developed community support systems which attempted to coordinate care across social support systems for the clientele admitted to the public system. But these CSP (community support programs) -where they existed - usually did not include financial responsibility. Monopoly grants dominated the financing; then waiting lists. Managed behavioral healthcare uses the concept of medical necessity to access care. This concept requires a medically diagnosable illness, a disability, or a substantial limitation in daily functioning, such a problems with work, school, or family. Psychotherapy sessions to help an individual with growth and development and interpersonal relations - individuals who function well in their jobs and families and have no illness - are generally not approved as medically necessary. Hospitals and solo practice psychotherapy complain about this restriction on having their services paid for. A major dilemma in public sector managed care remains the unwillingness of many public payers to integrate medically necessarily services with social supports.