Care Management and Cost Control | Managed Behavioral Health

Care Access

MBHOs traditionally require preauthorization to access treatment. MBHOs generally operate their own customer service centers, and when a member calls for a referral, an intake specialist asks the member a series of questions to establish the reason for the call, assess risk, acuity, specialty needs and member preference. After listening to the caller's concerns and explaining the nature of the caller's benefits, the intake specialist separates routine from urgent and emergency situations. More than 80 percent of incoming calls are generally for routine referrals; industry standards dictate that members receiving routine referrals must be seen by a provider within 10 business days. If a member's needs are urgent, an appointment is arranged within 48 hours, although the more stringent standard of 24 hours is adopted for some contracts. If an individual requires immediate, emergency services (e.g., he or she is suicidal or homicidal), referral is generally made to a hospital or inpatient facility if an immediate appointment is not available with a network practitioner. Most MBHOs employ a dedicated team of licensed crisis care managers, who are specially trained in emergency protocol, active listening, diffusing, and referral. Use of ambulance services and/or police may also be involved in diffusing hostile situations and transferring an individual to psychiatric facilities.

Predictive Modeling and Risk Assessment

High-service utilizers—generally individuals with severe and persistent mental illnesses such as schizophrenia and major recurrent depression—represent a small percentage of overall service users but account for a disproportionate, higher percentage of treatment resources and claims costs. MBHOs analyze claims and treatment data to identify high-risk members who have a history of high utilization and repeated hospitalizations.

Predictive modeling is the ability to forecast who those high-risk, potentially high-cost members are, and intervene in time to avoid preventable treatment costs. The degree of risk can be identified and members stratified accordingly, so care management resources can be applied most effectively and efficiently. MBHO care management resources tend to be in short supply, so it pays to use those limited resources to deliver the best clinical and economic value to both the member and the payer.

Performance Measurement

MBHOs typically measure provider network performance through a number of variables that include accessibility, utilization, and adequacy and appropriateness of treatment. Traditionally these performance data are collected after-the-fact through provider assessment reports and claims data. Today, however, some MBHOs are collecting member-reported and provider-reported data earlier on in the process to guide timely treatment interventions that can avert unnecessary emergency hospitalizations and contribute to more effective treatment outcomes. Profiling provider performance on clinical outcomes is an important step forward in the performance measurement arena.

Case Management

Case management is a term that refers to oversight of an MBHO member's treatment to ensure it is appropriate. Case managers employed by the MBHO coordinate the member's care in collaboration with treating providers, facilities and community resources, and often work with members and their families to ensure they continue to receive the appropriate level of care for their fluctuating needs. This ensures a cost-effective course of treatment in an appropriate setting. Potentially high service utilizers are identified so case managers can focus on those individuals with the greatest needs to ensure they continually receive appropriate treatment levels. Most MBHOs use an escalating series of models or protocols based on the patient's level of acuity and chronicity, which determine how frequently case managers monitor treatment. Case management goals are crisis stabilization, prevention of long-term disability, and reduced reliance on hospital care by facilitating patient engagement in outpatient treatment and community resources.

Utilization Review and Management

Utilization review is an activity that determines the medical necessity and appropriateness of treatment being provided, and is performed at various times including at the point of care (prospective review), during care (con-current review) and after treatment (retrospective review). While MBHOs generally perform this function, self-funded employers and health plans may purchase this service from stand-alone utilization review organizations. MBHOs utilize written criteria based on clinical evidence to guide the evaluation of the medical necessity, appropriateness, and efficiency of mental health and chemical dependency services.

Outcomes Management

In recent years, MBHOs have developed tools to assess treatment effectiveness and quantify outcomes, bringing technology, data, and increased objectivity to a field once dominated by subjective assessment. The measurement of outcomes concurrent with the treatment process is the most powerful approach to outcomes management because feedback to clinicians can shape care as it is being delivered. The objectives of outcomes management are to identify risks early so treatment interventions contribute to more positive outcomes, as well as prevent emergencies and unnecessary hospitalizations.

Coordination of Care

Behavioral disorders often coexist with each other (e.g., depression and substance abuse), and with medical disorders (e.g., depression and chronic heart disease). An individual may be seeing his or her primary care doctor for treatment of a physical disorder and a behavioral specialist for treatment of a mental disorder. Coordination of medical and behavioral health care services results in improved treatment outcomes for patients. When coordination of care does not take place, there are increased risks such as repeated or unnecessary testing and adverse drug reactions. A consumer in today's complex health care environment is faced with a mind-boggling array of organizations, programs, services, and providers, each of which can play a vital role in his or her care and successful recovery. Patients benefit from an interconnected series of care coordination protocols between behavioral health specialists, primary care/medical doctors, medical plans, MBHOs, pharmacy benefit managers and community affiliates.

Health care accrediting and regulatory bodies are pressing the managed care industry to integrate behavioral care into medical delivery systems. Even though progress has been made, much work is needed to create a truly integrated health care system.

Depression Disease Management Programs

Depression is a mental illness that often goes unnoticed, and it co-occurs with many physical illnesses such as diabetes and heart disease. It is increasingly a focus of disease management initiatives because of its chronic nature and large economic impact. MBHO depression disease management programs support the clinician–patient relationship and plan of care, and emphasize prevention of disease-related exacerbations and complications using evidence-based guidelines and patient empowerment tools. These programs require coordination among health plans, physicians, pharmacists, and patients. Disease management can improve patient outcomes and quality of life while potentially reducing overall health care costs.

Substance Abuse Relapse Programs

Addiction to alcohol and other drugs is a chronic condition, characterized by relapses. Therefore, the prevention of relapse is one of the critical elements in successful treatment. Standard chemical dependency treatment was once a 28-day inpatient treatment program. Since detoxification on an outpatient basis is more often recommended today than in the 1980s, only persons with severe withdrawal and other medical complications now require hospitalization (IOM, 1990a). Most substance abuse treatment experts today consider intensive outpatient treatment more effective for most patients in treating chemical dependency. Outpatient programs encourage individuals to remain sober while confronting their day-to-day living situations. In addition, most MBHOs today offer after-care programs to their members who complete a course of chemical dependency treatment. The programs are aimed at preventing relapse and often include telephonic support and self-help tools.