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Mental Health/Substance Abuse

Managed care is rapidly changing the delivery of mental health and substance abuse (MHSA) care by steering plan participants away from psychiatrists and inpatient facilities and toward less costly psychologists and outpatient centers. Generally, only persons considered to be a threat to themselves or to others are hospitalized. For those who are hospitalized, the average length of stay has been reduced significantly over the past 10 years. Decisions on where care will be provided, who will provide the care and the duration and intensity of treatment are usually made by the plan. There are three basic categories of managed mental health plans: integrated, carveouts and hybrids. Cost containment techniques, such as pre-authorization of treatment, utilization review and emphasis on treatment methods and settings are similar in all three types of plans. However, the structure of each is quite different.

  • Integrated plans use the same network of physicians for basic medical and MHSA care. MHSA medical professionals are considered specialists within the plan and patients must be referred to them by their primary care physician.
  • Carveout plans provide MHSA services only; basic medical services are provided under an entirely separate plan. Mental health clinicians who work for or contract with the MHSA vendor oversee patient treatment. Although promotional literature may imply that all health care services are provided under one plan, much of managed MHSA care is provided through carveout plans.
  • Managed care plans with a hybrid MHSA feature refer patients with complex or severe problems outside of the network while treating less severe cases in-network.

When reviewing a plan’s MHSA coverage, many questions about the plan in general are relevant. Here are additional matters to consider.

Access to Care

Most managed care plans require pre-screening and referral for MHSA treatments. This process is critical to patient satisfaction and to the ability to actually access appropriate care.

Q. How is MHSA care obtained?

A. Typically, enrollees must obtain a referral from their primary care physician, through an employee assistance program or, in some cases, by calling a dedicated MHSA phone line. A few plans permit self-referral, with a requirement that all care subsequent to the initial visit be pre-authorized.

Q. If phone referral is used, who answers the call? What percentage of calls are transferred directly to a clinician who can make a MHSA referral? What are the backgrounds of clinicians making initial assessments?

A. Patients should have immediate access to a person with clinical training. Registered nurses or physicians with MHSA training are best equipped to ask relevant questions and identify appropriate treatment options.

Q. How are MHSA providers compensated?

A. Recently, some plans have begun to compensate MHSA providers on a “case rate” basis. Under this system, the plan pays the provider a flat fee to hold a certain number of sessions with a specified individual. If the provider feels that the patient is “cured” in fewer sessions, the patient will be dismissed earlier. If, however, the patient is not cured within the specified number of sessions, he or she may be dismissed prematurely. Some plans will authorize additional treatment in severe cases, upon request by the provider. While case rate compensation may eliminate some utilization review hassles, it also may encourage providers to undertreat patients.

Q. In what other ways are plans controlling their MHSA obligations?

A. Many plans impose higher deductibles and copayments for MHSA treatments than for treatment of physical ailments. The Mental Health Parity Act (MHPA) (see pages 35-36) prohibits plans from imposing higher annual and lifetime dollar caps on MHSA treatment than the limits applied to general medical care. However it does not regulate MHSA deductible or copayment amounts, nor does it prohibit plans from imposing limits on days or the number of visits covered.

Plan Providers

Q. What is the plan’s mix of psychiatrists, psychologists, social workers and chemical dependency specialists?

A. It is important that the provider group meets the needs of plan participants. Some patient groups may have a high incidence of substance abuse problems, yet many managed care mental health/substance abuse plans are run by people who are not specifically trained in treatment of substance abuse. They may not recognize substance abuse problems and may provide inadequate treatment.

Q. What are the qualifications of primary care physicians and specialists who treat MHSA patients?

A. In many integrated or hybrid plans, primary care physicians are responsible for identifying MHSA problems and making referrals. Those physicians should have some training in mental health and substance abuse disorders.

Q. Does the plan insure diversity of providers? Does the system try to connect patients with culturally appropriate providers, if the patient wishes?

A. MHSA providers should mirror the diversity of the patient population, to the extent possible. Intake staff should ask callers whether they have a provider preference. Upon request, staff should provide information on the gender, race and linguistic ability of providers and, if the provider so directs, on sexual orientation.

Q. Does the plan offer a variety of levels of care? How does the plan network reflect this approach?

A. The network should include a full range of services to properly address the needs of people with differing conditions. Networks should include acute care and partial hospitalization options, day treatment centers, halfway houses or rehabilitation programs, and group and individual treatment options.

Management of Treatment

Q. What are the treatment authorization protocols? For example, how many visits or days are authorized initially and upon subsequent reviews? Who controls this, and what level of “proof” does a provider need to receive authorization?

A. Plans vary widely on this issue. Some plans that advertise unlimited benefits authorize only one or two initial visits and require frequent re-authorizations, which may discourage those in need of treatment from obtaining it. Even if the patient does seek re-authorization, the plan may claim further treatment is medically unnecessary.

Q. What level of ongoing care is provided following major MHSA episodes, such as suicide attempts or alcohol detoxification?

A. Studies have shown that follow-up MHSA treatment and long-term monitoring of those with chronic conditions greatly improves outcomes. Follow-up care might consist of individual or group therapy, or even access to a 24-hour hot line.

Q. Does the plan require pre-certification for inpatient hospitalization or access to other intensive MHSA treatment?

A. If the answer to this question is yes, a penalty-free post-admission review should be permitted in crisis situations.

Q. What is the plan’s emphasis on life management programs such as weight control, stress management, smoking cessation and family counseling?

A. These programs can be good preventive and early detection tools, similar to preventive care coverage under the non-mental health/substance abuse portion of the plan. However, as plans attempt to cut costs, these services are often no longer covered.

Q. Does the plan offer critical incident stress debriefing services and group therapy following a violent workplace incident?

A. Studies show that employees can experience symptoms of post-traumatic stress disorder following an incidence of violence in the workplace. Treatment following the incident can be critical.

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