Nov 18, 2008

Behavioral Health | BENEFIT CARVE-OUTS

Behavioral Health
The providing of behavioral health benefits has always been an area of difficulty for medical expense plans. There is less uniformity in treatment standards for mental health, alcoholism, and drug addiction than for most other medical conditions. This, and the difficulty of monitoring treatment, has often led to unnecessary, expensive, and dangerous treatment by less-than-scrupulous providers of behavioral health care. Historically, benefit plans addressed these problems by having very limited benefit levels. But even these benefit levels still had a tendency to encourage more expensive inpatient care over outpatient treatment, which in most cases appears to be as clinically effective. In addition, there was little follow-up care after treatment. With rapidly increasing costs for behavioral health, employers and providers of benefit plans are increasingly carving out this benefit by contracting with vendors that use managed care techniques. However, even with the use of carve-outs, benefit plans still continue to limit behavioral health benefits to a level significantly below that for other medical conditions.

Characteristics of a successful behavioral health program, whether it be a carve-out arrangement or not, should include the following:

  • The use of case management to design and coordinate treatment plans and to monitor the need for follow-up care.

  • A mechanism for referring a patient to the program. In many cases, this is through a gatekeeper who is a primary care physician. However, there is also increasing coordination of behavioral health programs with employee-assistance programs

  • The development of a provider network that specializes in behavioral health. In addition to physicians, the network will include psychologists and therapists. It will also include alternatives to hospital treatment, such as residential centers, halfway houses, and structured outpatient programs. Benefits may or may not be provided if nonnetwork treatment is sought. If it is covered, there is usually a lower benefit level than for network treatment.

  • Patient access to care on a 24-hour basis. Persons who have behavioral health problems often need immediate crisis intervention. Of course, the availability of such care needs to be well communicated to patients.

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