Behavioral Health Providers

The Specialty Network

A behavioral specialty network must cover a wide range of behavioral treatment needs and levels of care. A typical behavioral health specialty network includes individual (solo) practitioners and multispecialty group practices consisting of clinical psychologists (PhDs, PsyDs, EdDs), social workers (LCSWs, LISWs, ACSWs, MSWs, CISWs), masters-level therapists (MPSYs, MFTs, MFCCs, LMFTs, LPCs), psychiatric nurses (ANRPs, RNs), and psychiatrists. A network may also include medical doctors who specialize in addictionology, and developmental behavioral pediatricians (DBPs) to improve access for children with special needs.

In addition to behavioral specialists, the network includes inpatient facilities and programs that accommodate the broad spectrum of treatment needs. Acute inpatient facilities are designated for the most acute treatment needs, meaning individuals who are unable to care for themselves in some way and may be suicidal or homicidal. Partial hospital programs (sometimes called day treatment) offer intensive treatment during the day, but patients return home overnight. Finally, intensive outpatient programs are designed for patients who need more intensive treatment than weekly outpatient therapy provides, but they require fewer hours each day than partial or day facilities provide. Each program or facility may specialize in a certain age group (adult, geriatric, adolescent, child), while some programs focus on mental illnesses only, others on chemical dependency, and a few specialize in co-occurring disorders. MBHOs employ specific criteria to authorize facility-based care and treatment programs for their members, and licensed care managers provide oversight to ensure treatment plans and lengths of stay are appropriate.

Provider Qualification: The Credentialing Process

MBHOs perform primary source verification of practitioners' credentials before they are accepted to practice in their network and serve their members. Areas of scrutiny include investigation into a provider's education, board certification, background and work history, liability insurance and malpractice coverage, practice information (addresses/hours/facility description), population, language and treatment specialties, and hospital admitting privileges. MBHOs conduct recredentialing—typically every two to three years—to ensure that providers maintain quality standards.

Meeting Group Needs: Customized Networks

MBHOs often custom-build behavioral provider networks to meet a group's diverse geographic, cultural, language and specialty needs, as well as member preferences. Standards for member access and availability to services are designed to ensure that members have a choice of providers—outpatient practitioners, inpatient facilities and specialized treatment programs—across the continuum of care, within an acceptable travel distance, and with appropriate clinical subspecialties. Most MBHOs forge alliances with community-based mental health and substance abuse treatment providers to provide both covered services and as referral sources for noncovered services, and they develop these linkages based on the particular needs of the membership being served. Rural areas often have a limited number and diversity of practitioners and facilities. Consequently, Medicaid-supported community mental health centers often dominate as the de facto service provider for a wide range of treatment needs. To increase access to treatment in rural areas, MBHOs may at times work with Medicaid-supported providers to establish these centers as referral options for their members. In addition, MBHOs are beginning to consider telephonic or web based psychiatry to serve rural populations that do not have access to local professionals.

Managed Behavioral Health Care

The term "behavioral health" refers to mental health and substance abuse services provided by behavioral health specialists. Managed behavioral health benefits are subject tothe general forces of managed care while also facing unique issues and challenges of their own. In recent years there has been a heightened focus on behavioral health benefitsbecause they are a key contributor to increased employee productivity and lower medical costs. Of an estimated 250 million Americans with health insurance, 66 percent are enrolled in some type of specialty managed behavioral health program.

Mental Illnesses and Other Behavioral Disorders

The most severe mental illnesses such as schizophrenia, bipolar disorder and major depressive disorder are generally considered biologically based disorders that affect thebrain, profoundly disrupting a person's thinking, feeling, mood, ability to relate to others and capacity for coping with the demands of life. They cannot be overcome through "will power" and are not related to a person's character or intelligence. Nonbiologically based mental disorders can also severely impact an individual's functioning. Early identification and treatment is of vital importance; according to Dr Thomas Insel, Director of the National Institute of Mental Health, between 70 and 80 percent of individuals suffering from depression experience significant reduction of symptoms and improved quality of life through psychotherapy and/or medication.

Mental disorders can loosely be categorized into the following categories:

1. Adjustment disorders (e.g., situational stress).
2. Anxiety disorders (e.g., panic disorder).
3. Childhood disorders (e.g., autism).
4. Eating disorders (e.g., anorexia).
5. Mood disorders (e.g., major depressive disorder).
6. Cognitive disorders (e.g., dementia).
7. Personality disorders (e.g., antisocial personality disorder).
8. Psychotic disorders (e.g., schizophrenia).
9. Substance-related disorders (e.g., alcohol/drug dependence).

The most serious and disabling conditions such as major depression, schizophrenia, bipolar disorder, panic disorders and obsessive compulsive disorders affect five to 10 million adults (2.6 to 5.4 percent) and three to five million children ages five to 17 (5 to 9 percent) in the United States.

The Need for Behavioral Benefits

Behavioral disorders can have a devastating impact on affected individuals, their families and society. Mental illness is the number one cause of disability in the United States, Canada and Western Europe, according to a 2001 study by the World Health Organization. It has now surpassed heart disease, which was the leading cause of disability as recently as 1996. Alcohol consumption accounts for up to 40 percent of industrial fatalities and 47 percent of industrial injuries. A study published in the American Journal ofHealth Promotion found that workers experiencing high stress are more than two times more likely to be absent more than five times per year. Given these alarming statistics, it stands to reason that health care benefit purchasers gain from providing their workforces with relatively inexpensive mental health, chemical dependency and employee assistance programs that cover the full spectrum of behavioral needs. Unfortunately, behavioral benefits are the least understood and most poorly compensated of all thepossible components of a health benefits package.

Common Misperceptions

Most people are unaware of the possible inadequacy of behavioral health benefits found in insurance plans, since it is falsely assumed that mental health and chemical dependency treatment needs are fully covered under medical plans, and in addition, that employee assistance programs fill in the gaps. Unfortunately, these are common misconceptions. The mandated behavioral benefits in a medical plan are limited to emergency assessment and crisis coverage. Mental health "parity" riders—legislatively mandated add-ons to medical benefit plans—are limited in the scope of disorders they cover. Employee assistance programs focus on workplace productivity, and offer only a limited number of visits for emotional counseling. To fully understand behavioral health benefits and the multitude of ways they are structured, it helps to take a brief look at thegrowth of the managed behavioral health care industry.