The Impact on Case Management

States are introducing managed care into the public mental health system, often through a contract with a private behavioral health company that "carves out" this piece of business from other health care for which the state may contract. A major impetus for this trend is state governments' desire to manage Medicaid costs. With the advent of behavioral health carve-outs, the trend of the private organizations that contract with states is to minimize costs wherever possible and maximize profits. A segment of behavioral health care services that has been significantly affected by this push to achieve "efficiencies" is case management.

In its September, 1997 study of behavioral health organizations entitled, "Stand and Deliver: Action Call to a Failing Industry," the National Alliance for the Mentally Ill (NAMI) published a "report card" which generally gave the private behavioral health industry a failing grade. One of the elements of its assessment included case management, which it found lacking under managed care compared to what a comprehensive case management service should be.

The NAMI report indicates that people with the most disabling brain disorders can achieve a significant level of recovery if the appropriate treatments and supports are available in the community. The proper referral and follow-up can achieve this if an effective case management system is in place. "More than two decades of research have shown that a model of intensive case management - the Program for Assertive Community Treatment (P/ACT)-constitutes effective and cost-effective care for people with the most disabling illnesses by decreasing hospital stays, improving functioning and quality of life, and promoting patient and family satisfaction."

The privatization of behavioral health has minimized the effectiveness of case management and even intensive case management, which are terms that have come to mean many things. "Intensive case management programs modeled after P/ACT use a multi-disciplinary team of care-givers, including a psychiatrist. This form of intensive case management provides 24-hour, seven-day-a-week care, reaches out to the individual disabled by a serious brain illness, and assures the full range of treatment and supports necessary to effectively serve individuals with these illnesses," according to the NAMI report. However, the onset of managed care and a push to achieve cost savings means that case management simply becomes a gate-keeping function aimed at moving patients to less costly treatments.

A critical comment in the NAMI report states that, "The ‘gatekeepers’ for the doctors aren’t trained well enough to recognize a crisis and refer intelligently. They don’t recognize side-effects of medication on a regular basis. They don’t have a 24-hour crisis line. The do not have a pharmacist on duty. The case managers, on the whole, need to be fired. They do not help the caregivers with anything."

How the Behavioral Health Organizations Measure Up

NAMI rated nine private behavioral health organizations according to their responses to a survey questionnaire. The marks were pass, fail or incomplete. A passing grade signaled at least a minimal recognition of their standards, but with improvement required. "Incomplete" denoted a failure to provide relevant information or being in the planning and development phase for a measure. A failing grade was given for approaches that clearly run counter to high-quality clinical care and NAMI’s measures for success.

Overall Industry Performance

According to the NAMI report, the managed behavioral health care industry gets a failing grade for how it serves people with severe mental illnesses in the public sector. Since the behavioral health organizations were contracted to manage the states’ mental health programs, there is evidence of some companies attempting to adapt to public sector needs. In general, however, there is too much focus on "restrictive gate-keeping," there are too many barriers to care," according to NAMI, and "leadership has failed too often to provide the important clinical and support services necessary for people with disabling and chronic disorders. Even measures of success given a passing grade fall short of excellence and reveal room for growth."

AFSCME Public Policy Department
August 1998