SD44 - The Effects of Managed Care and HMO Administration of Mental Health Benefits on Service Providers
Executive Summary: Findings Managed Care has become a necessary means to control health care expenditures. Its report card is not definitive about cost savings beyond the ability to reduce use of certain types of health care services. Managed care's ability to provide the health care system with the cure is an evolving system that addresses only one dimension of the health care system. The literature suggests that there are many myths about managed mental health care, but there are definitely changing roles and realities. For the Commonwealth of Virginia, the SJR 107 study on Managed Care attests to the concern expressed by clinicians, in both the private and public sectors, about the negative effects that managed care have had. Effects of Managed Care: Cost Shifts Managed Care, as a growing practice, contributes to the following: • Increased Private Sector Charity and Low Cost Care • Increased Capitation/Cost-Shifting • Over $1 million Cost-Shifting to the Public CSBs Annually Professional Concerns • Professional Sentiment that It Affects the Quality of Care • Major Professional Confidentiality Issues • Intrusive Utilization Review • Orientation of "Managed Reimbursement" versus Managed Care • The Erosion of Extended Treatment Plans • Reduced Access to Private Sector Care that shifts people to • Private Charity Care • Public Sector Waiting Lists • No Care at all and Deteriorated Mental Status Part of the Solution The above are realities and manifestations of the problem and not an indictment of Managed Care. Managed Care principles are needed in today's health care arena. The MH/SA community recognizes this reality and wants to partake in the system prescription. However, all parties will be needed to make it work with credibility and quality. Recommendations Managed care has been characterized as the responsibility of the many parties involved in the process. This framework is proper for recommendations engendered by the SIR 107 study. General Assembly Recommend that the Special Advisory Commission on Mandated Health Insurance Benefits work to ensure action on the following Managed Care related recommendations: • Support Mental Health and Substance Abuse Services in the Essential Health Services Panel and 1993 General Assembly actions. • Support the mental health services benefit conversion option approved by the Special Advisory Commission on Mandated Health Insurance Benefits. This conversion option provides flexibility in mandated mental health service coverage offered in insurance packages by providing a range of services in varied treatment settings. * Inpatient care: 20 days for adults and 25 days for children and adolescents under the age of 18 on the same terms and conditions as coverage for inpatient medical/surgical treatment. * At patient discretion, conversion of up to 10 days of inpatient benefits to partial hospitalization on the basis of one inpatient day for at least 1.5 days of partial hospitalization. * 20 outpatient visits with the first 5 on the same terms and conditions as medical/surgical outpatient visits, and the remaining 16 with no greater than a 50% coinsurance payment. * Medication management outpatient visits covered as medical/surgical outpatient visits and not against limits on mental health outpatient visits. • Authorize the collaborative development by the SCC, DMHMRSAS, Department of Health Professions, and other involved agencies and governmental entities of a process for enabling Managed Care practice and the evaluation of their professional conduct. Bureau of Insurance • Require all Managed Care firms to comply with the developed criteria and assurances prior to conducting business in the Commonwealth. • Monitor the conduct of Managed Care firms with the Department of Health Professions and DMHMRSAS through the administration of: * An Independent Case Disposition Appeals Panel * A Complaint Tracking and Disposition System * Requirement that all Managed Care firms advertise appeal and due process rights. Managed Care Firms Doing Business in Virginia • Comply with standards of care and confidentiality safeguards • Implement equitable internal appeals procedures. • Conduct quality of care assessments and long-term evaluations. • Maintain and report performance data on service capitations and client prognosis and disposition. • Abide by sec Independent Review Panel Determinations. DMHMRSAS and CSBs • Track managed care trends and cost-shifting to State Hospitals and CSB programs. • Ensure that Managed Care Standards of Care criteria produce appropriate levels of clinical services and full insurance benefit use. • Report Managed Care practices that reduce access and cause cost-shifting to private sector charity care or public sector programs to see and the Secretary of Health and Human Resources for action. • Work with Virginians for Mental Health Equity, Johns Hopkins, academic resources and consumer groups to study insurance mandates, utilization issues, and methods to track Managed Care trend data. Practitioners and Institutions • Cooperate, collaborate to make managed care work equitably for clients. • Exercise all judicious appeals means. • Assure confidentiality and professional ethics with respect to patient care and patient records. • Recognize that Managed Care can reduce costs, but has the price of quality loss and cost-shifting to less effective and appropriate treatment. • Educate consumers about the need for managed care and the consequence that if Managed Care is conducted too aggressively, the public will pay. Employers and Businesses • Insist that only reputable, credentialed Managed Care firms conduct business in Virginia. • Evaluate Managed Care insurance packages based on quality performance and not just cost-savings. • Recognize that mental health and substance abuse needs do not disappear, if not treated. When insurance per diems do not capture externalities, the private sector must allocate more charity care and the public sector cannot respond due to long-standing waiting lists. Business as a taxpayer will pay inordinately. Recognize that "we can pay now or pay more later." Consumers • Hold all parties responsible for Managed Care system effects on quality treatment. • Exercise appeals procedures. • Expect responsible performance by Managed Care firms and insist that the sec report annually on the performance of Managed Care firms doing business in Virginia. • Advocate for MH/SA insurance parity. • Build alliances to assist all parties to make this prescription work. |
Menu
Published Documents
