by E. Clarke Ross, D.P.A. Executive Director
American Managed Behavioral Healthcare Association
Printed in the December 7, 1997 Tallahassee Democrat

1. The establishment and operation of integrated and coordinated delivery systems. The goal here is to coordinate mental illness and addiction disorder treatment across professional disciplines on behalf of a health plan enrollee. Moreover, we strive to coordinate behavioral health services with primary and other health treatment. This results in a focus on patient-centered rather than professional practitioner specialty-centered care.
2. The establishment, management, and operation of accountability mechanisms. The goal here is to have health plans, their management agents, and their providers publicly document their accountability for positive clinical outcomes and consumer satisfaction.
3. Management of health benefits within a purchaser's financial constraints. Regardless of the form of health plan financing, purchasers' demand that behavioral healthcare expenditures be constrained.

Experiences with managed behavioral healthcare have been both positive and negative. Some of those experiences include:

1. 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. These experiences are well documented by independent professionals and academics, such as RAND Corporation, William M. Mercer, Institute of Medicine, Medstat Group, Harvard University, Brandeis University, and University of California-Berkeley.
2. Services are provided through integrated and coordinated delivery systems. The health plan management agent develops and manages coordinated care processes. Many mental health professionals working in solo practice isolation are not trained nor are their practices organized to coordinate their services to treat a patient's entire health situation. Some solo practice psychotherapists are particularly resistant to coordinating and integrating their care. Managed care plans frequently have not effectively yet integrated mental illness and addiction disorder treatment providers. And we have only a few pockets of excellence in integrating behavioral healthcare with physical medicine.
3. Accountability mechanisms are evolving but have a long way to go. Prior to managed care treatment plans were frequently not specific or goal oriented. Under managed care there are standardized practice protocols. Providers must justify their treatment plans. Providers, health plans, and the management agents must document that patients get clinically better and that consumers are satisfied with their experiences. The state-of-practice in accountability measurement remains focused on largely process measures rather than true outcomes. We are learning about consumer dissatisfaction because for the first time we are now systematically tracking consumer opinion.
4. Purchasers' focus on value-based purchasing - the relationship of resources to outcomes - has significantly restrained behavioral health expenditures. Within cost constraints, health plans, their management agents, and their providers must document performance. While mental health practitioners are now expected to integrate and coordinate their care and work in limited member networks emphasizing documented performance, they are also being paid with discounted fee structures. All of these paradigm changes have resulted in practitioner complaints.
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. Managed behavioral healthcare uses the concept of medical necessity to access care. This concept requires a diagnosable illness, a disability, or a substantial limitation in daily functioning, such as problems with work, school, or family. Psychotherapy sessions to help an individual with growth and development - individuals who function well in their jobs and families and have no illness - are generally not approved as medically necessary. The less clear-cut, more open ended, non-directive therapies of the past are no longer being reimbursed. As a result, solo practice psychotherapists who previously were reimbursed for these activities express their unhappiness.
6. The focus on integrating and coordinating care, on ensuring positive clinical outcomes, and on guaranteeing reimbursement for medically-necessary care has undermined and challenged traditional notions of therapist-patient confidentiality. This is a major challenge.
7. The focus on appropriate and effective treatment and the focus on resource-based care have raised important issues about accessing pharmacy benefits.
8. Purchasers and legislators across the country are moving towards flexible and comprehensive mental illness benefits, know as the movement toward "parity" in health benefit design. It is managed care, with its focus on appropriate and demonstrated effective treatment, which convinces purchasers and legislators that "parity" is affordable.

Resource-based care which also focuses on accountability, integration, and patient-centered care is a major paradigm shift for both practitioners and consumers.The ability of health plans to meet the needs and expectations of consumers will significantly impact how the management of care will be structured in the coming years.

The author appreciates the editorial review by Ian Shaffer, M.D., Chief Medical Officer, Value Behavioral Health, and immediate-past chair of AMBHA.