Concise Guide to Managing Behavioral Health Care Within a Managed Care Environment (Concise Guides)

CONCISE GUIDE TO

Managing Behavioral Health Care Within a Managed

Care Environment

Washington, DCLondon, England

CONCISE GUIDE TO

Managing Behavioral Health Care Within a Managed

Care Environment

Michael Isaiah Bennett, M.D.

Medical DirectorMental Health CaseManagement

Plymouth, Massachusetts

Note: The authors have worked to ensure that all information in this book concerning drug dosages,schedules, and routes of administration is accurate as of the time of publication and consistent withstandards set by the U.S. Food and Drug Administration and the general medical community. Asmedical research and practice advance, however, therapeutic standards may change. For this reasonand because human and mechanical errors sometimes occur, we recommend that readers follow theadvice of a physician who is directly involved in their care or the care of a member of their family. Aproduct’s current package insert should be consulted for full prescribing and safety information.

Books published by American Psychiatric Publishing, Inc., represent the views and opinions of theindividual authors and do not necessarily represent the policies and opinions of APPI or the AmericanPsychiatric Association.

Copyright © 2002 Michael Isaiah Bennett, M.D.ALL RIGHTS RESERVED

Manufactured in the United States of America on acid-free paper06 05 04 03 02 5 4 3 2 1First Edition

American Psychiatric Publishing, Inc.1400 K Street, N.W.Washington, DC20005www.appi.org

Library of Congress Cataloging-in-Publication DataBennett, Michael Isaiah, 1945–

Concise guide to managing behavioral health care within a managed care environment / Michael Isaiah Bennett.—1st ed.

p. ; cm. — (Concise guides)Includes bibliographical references and index.ISBN 0-88048-738-0 (alk. paper)1. Managed mental health care. 2. Psychotherapy—Practice. I. Title. II. Concise guides

(American Psychiatric Publishing)[DNLM: 1. Mental Health Services—organization & administration—United States.

2. Case management—organization & administration—United States. 3. Ethics, Clinical—United States. 4. Insurance Benefits—economics—United States. 5. Managed Care Programs—organization & administration—United States. 6. Marketing of Health Services—organization &administration—United States. WM 30 B472c 2002]RC480.5 .B446 2002362.2—dc21

2002018298

British Library Cataloguing in Publication DataA CIP record is available from the British Library.

CONTENTSIntroduction to the Concise Guides Series . . ixIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . xiTools for Managing Care . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Balancing the Needs of Patients With the Need for Resource Preservation . . . . . . . . . . . . . . . . . xiii

Two Misunderstandings: Managed Care and Managed Care Organizations . . . . . . . . . . . . . . . . . . . xv

Tools for Managing Managed Care Organizations. . . . . . . xviUnderstanding the Market . . . . . . . . . . . . . . . . . . . . . . . xviShaping the System . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviiReferences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . xxi

1 Managing Care Ethically . . . . . . . . . . . . . . . . . .1Defining the Ethical Goal . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Determining Benefit Eligibility:

Understanding Eligibility Criteria . . . . . . . . . . . . . . . . . . . 3DSM-IV-TR Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . 4Non–DSM-IV-TR Behavioral Problems. . . . . . . . . . . . . 5Likelihood of Improvement. . . . . . . . . . . . . . . . . . . . . . . 5Benefit Exclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Determining Medical Necessity . . . . . . . . . . . . . . . . . . . . . . 6Assessing Risk of Harm . . . . . . . . . . . . . . . . . . . . . . . . . 7Assessing Treatment Effectiveness and

Risk of Relapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Assessing Nonprofessional Support. . . . . . . . . . . . . . . . . 8Comanaging With Patients . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Sharpening Personal Choices . . . . . . . . . . . . . . . . . . . . . 10Obtaining Other Resources . . . . . . . . . . . . . . . . . . . . . . 11

Working With Managed Care Organizations . . . . . . . . . . . 11Knowing How to Obtain Special Services. . . . . . . . . . . 11Obtaining Deserved Benefits . . . . . . . . . . . . . . . . . . . . . 12Acquiring Leverage Over Contracts . . . . . . . . . . . . . . . 13

Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2 Managing Nonacute Care . . . . . . . . . . . . . . . .19Determining Nonacute Coverage . . . . . . . . . . . . . . . . . . . . 20

Evaluating Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Comanaging With Patients. . . . . . . . . . . . . . . . . . . . . . . 22

Deciding How Much Nonacute Care Is Necessary . . . . . . . 22Meeting the Initial Need. . . . . . . . . . . . . . . . . . . . . . . . . 23Determining Treatment Amount and Length. . . . . . . . . 23Comanaging With Patients. . . . . . . . . . . . . . . . . . . . . . . 24

Obtaining Outpatient Benefits From Managed Care Organizations . . . . . . . . . . . . . . . . . 25

Gaining Access to a Company’s System of Care. . . . . . 25Responding to Reviews . . . . . . . . . . . . . . . . . . . . . . . . . 26Changing to Unmanaged Treatment . . . . . . . . . . . . . . . 27Understanding Denials and Making Appeals. . . . . . . . . 28

Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

3 Managing Acute Care . . . . . . . . . . . . . . . . . . .33Determining Entitlement to Acute

Behavioral Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . 34Determining Medical Necessity of Acute Care. . . . . . . . . . 35

Choosing Levels of Care . . . . . . . . . . . . . . . . . . . . . . . . 35Changing to Lower Levels of Care . . . . . . . . . . . . . . . . 39Administering Active Treatment . . . . . . . . . . . . . . . . . . 40

Preparing Plan A and Plan B . . . . . . . . . . . . . . . . . . . . . 40Comanaging Acute Care With Patients . . . . . . . . . . . . . 41

Obtaining Acute Care Benefits From Managed Care Organizations . . . . . . . . . . . . . . . . . 42

Gaining Access to Acute Care and Aftercare . . . . . . . . 42Undergoing Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Appealing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

4 Marketing to Managed Care Organizations . .51Presenting Credentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Responding to an Interview. . . . . . . . . . . . . . . . . . . . . . 51Avoiding Profiles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Meeting an MCO’s Unadvertised Needs . . . . . . . . . . . . . . 57Providing Regional and Special Clinical Services . . . . 58Offering Other Special Services . . . . . . . . . . . . . . . . . . 58Improving Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Appearing at the Hour of Need . . . . . . . . . . . . . . . . . . . 59Demonstrating Need . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Enhancing Incentive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Contracting as a Group . . . . . . . . . . . . . . . . . . . . . . . . . 60Seeking Allies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

5 Managing Utilization Review. . . . . . . . . . . . . .65Advocating for Good Managed Care . . . . . . . . . . . . . . . . . 66

Maintaining a Clinical or Fiscal Barrier . . . . . . . . . . . . 67Reviewing Medical Necessity . . . . . . . . . . . . . . . . . . . . 68Promoting Standards of Practice . . . . . . . . . . . . . . . . . . 68Educating Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Pinpointing Patient Influence

Over Resource Decisions . . . . . . . . . . . . . . . . . . . . . . 69Encouraging Realistic Decisions . . . . . . . . . . . . . . . . . . 70

Finding Support for Quality Improvement . . . . . . . . . . . . . 70Closing the Seams Between Systems . . . . . . . . . . . . . . . . . 71Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

ix

INTRODUCTIONto the Concise Guides Series

The Concise Guides Series from American PsychiatricPublishing, Inc., provides, in an accessible format,practical information for psychiatrists, psychiatry resi-dents, and medical students working in a variety oftreatment settings, such as inpatient psychiatry units,outpatient clinics, consultation-liaison services, andprivate office settings. The Concise Guides are meantto complement the more detailed information to befound in lengthier psychiatry texts.

The Concise Guides address topics of special con-cern to psychiatrists in clinical practice. The books inthis series contain a detailed table of contents, along withan index, tables, figures, and other charts for easy access.The books are designed to fit into a lab coat pocket orjacket pocket, which makes them a convenient sourceof information. References have been limited to thosemost relevant to the material presented.

Robert E. Hales, M.D., M.B.A.Series Editor, Concise Guides

This page intentionally left blank

xi

INTRODUCTION

What can help behavioral health clinicians providemanaged care in an ethical, professionally satisfyingway while they deal with managed care organizations(MCOs)? Answering this question became a personalquest in 1993, when, after 16 years in public psychiatry,I expanded my private outpatient practice by contract-ing to join as many MCO networks as possible. Mygoal as a practicing clinician was to provide good man-aged care using the tools that I had acquired in thepublic sector. In addition to balancing patient needsagainst a mandate to minimize costs, my priorities in-cluded obtaining referrals, getting paid a reasonableamount for my services, and being morally satisfiedwith my work. At the same time that I became a fee-for-service network provider, I also began workingfor an MCO as a salaried associate medical director.I hoped that my experience as an MCO providerwould help me to improve the system of care as anadministrator and that my experience as an MCOadministrator would help me as a provider to make thesystem work for the benefit of my patients and my-self.

xii

My public sector experience had given me an en-thusiastic respect for the art of satisfying patients’needs on a limited budget. Initially, I had thought thatlimited resources would inhibit my creativity, reducemy access to essential tools, and force me to providesecond-class care. Instead, the discipline of continuallyevaluating the cost-effectiveness of treatment, and thepartnership I developed with a patient as we discussedthe problem of limited resources, seemed to bring outthe best in both of us. It grounded us in reality by re-quiring us to ask ourselves whether the investment wewere making in change was likely to be effective orwould be better put into accepting the limits of realityand getting on with life (Bennett and Bennett 1984). Ifmanaging care means doing the best one can with lim-ited resources, and assuming that resources are not toolimited, practicing managed care not only protectscommunity resources but also improves the quality ofclinical work.

Since I left the public sector, I have experienced agreat deal of private sector managed care on both sidesof the fence, as network provider and administrator,and have gained insights along the way that I believecan be helpful to my colleagues. I have encounteredobstacles to my joining MCO networks as a serviceprovider and to my extending contracts to valued pro-viders as an administrator. I have persuaded caremanagers that my patients’ insurance should pay fortreatment and have been persuaded of the same thingby clinicians in all parts of the country in my role as a

xiii

physician advisor in an MCO. I have worked with myfellow providers to pressure MCOs into improving theirsystems and have worked with fellow MCO admin-istrators to motivate our company’s fiscal managers topay for quality improvements. Along the way, throughall of my varied experiences, I have encountered manygood people who wished to make a far-from-perfectsystem provide good care.

■ TOOLS FOR MANAGING CARE

Balancing the Needs of Patients With the Need for Resource Preservation

One insight that I gained in the public sector that iseven more true in the private sector is that managingcare requires clinicians to learn new skills and thatacquiring these skills is the key to enjoying one’s work,practicing managed care ethically, and dealing withMCOs. In the public sector, new skills were the un-expected result of our efforts to stretch fixed resourcesto cover the mental health care needs of a community.At the Massachusetts Mental Health Center, where weoffered the only inpatient care for uninsured membersof a catchment area population of 300,000 Boston andBrookline residents, we never had more than a few un-occupied beds on any given day, and on bad days wewere forced to admit new patients to mattresses in thecorridor. To prevent our resources from becoming de-pleted, we needed to find alternatives for admissionwithout endangering the safety of patients we chose not

xiv

to admit or otherwise compromising the quality of theircare. From this experience, we arrived at a working defi-nition of managed care: a method of practice that bal-ances the needs of the individual patient against theneed for resource preservation. Resource preservation,in a public sector system, ensures the availability ofcare for the community (Sabin 1994a, 1994b).

As time passed, we developed new ways to managerisks, improve efficiency, and arrive at an ethically ac-ceptable outcome. My colleagues were the first in thecountry to develop intermediate care programs thatoffered acute care services in outpatient settings atreduced cost. Each program contained some but not allelements of inpatient treatment, providing a continuumof care between the least intensive outpatient therapyand the most intensive locked inpatient program (Gude-man et al. 1983; Schreter et al. 1997).

In response to the availability of these new options,our assessment techniques evolved to emphasize care-ful risk assessments and a search for family resourcesthat could substitute for institutional, professional carewhenever possible. As a general rule, we sought theleast intensive local program that would meet the pa-tient’s needs without providing unnecessary services.We developed a hierarchy of treatment priorities: first,protect the patient’s safety; then, provide treatmentsthat are likely to work (Glazer 1992); finally, saveresources whenever possible. By using new skills andtaking advantage of all available resources, we couldbalance the goals of good treatment and resource con-

xv

servation. We were, in Sabin’s (1996) words, “not chal-lenged by looking the patient directly in the eye” as weexplained why the patient’s care would meet his or herneeds, including the steps we took to minimize costs.Indeed, we often found that the process of dealing withresource limitations stimulated our patients to becomemore active managers of their own care and more will-ing to deal creatively with the limitations of their prog-noses.

Two Misunderstandings: Managed Care and Managed Care Organizations

As we gradually merged clinical and resource manage-ment into a single professional role, major differencesdeveloped between ourselves and our private sector col-leagues in the way we defined our responsibilities andthose of the mental health system. When insurance com-panies began to promote managed care in the privatesector, many of our colleagues did not realize that man-aged care was a method of clinical practice in additionto being a method of insurance administration. Theyalso did not realize that the obligation to fund managedcare was forcing insurance companies to assume newresponsibilities for the availability and quality of clini-cal care as they evolved from cost managers to systemproviders. If a company’s usual network of servicescould not meet the needs of its insurance subscribers (ormembers, as they were now called), its care managerswere responsible for finding a solution. If a companydeclined to pay for services that a patient deserved, its

xvi

physician advisors were expected to hold it accountable,and if they did not, other advocates were prepared tointervene on a patient’s behalf. In addition to being aninsurance company and a manager of service utilization,an MCO bears responsibility for clinical care.

■ TOOLS FOR MANAGING MANAGED CARE ORGANIZATIONS

The tools for practicing managed care that I acquired inthe public sector served me well when it came to devel-oping treatment plans, explaining them to patients, andassuring MCO care managers that I knew what aninsurance benefit should cover. For those of my col-leagues who are interested in practicing managed carebut are unfamiliar with its techniques, this book pro-vides a guide. General principles for managing care aredescribed in Chapter 1; in Chapters 2 and 3, these prin-ciples are applied to the practical management of non-acute and acute care.

Understanding the Market

As I made the transition to private sector managedcare, I encountered a marketplace that had suddenlybecome hostile to service providers who worked inlarge urban areas where MCOs could require a majorityof the population to deal with network clinicians exclu-sively. Although managed care skills enhanced theappeal of one’s services to MCOs, one nevertheless

xvii

found many MCOs unwilling to contract with a new pro-vider, regardless of his or her skills, because they con-sidered their networks full. I discovered that there aremany ways of enhancing the market value of one’s ser-vices. One way is to provide specific services that arein higher demand; another is to affiliate with other cli-nicians and clinical organizations to provide a packageof services while enhancing one’s influence over re-gional markets. Improving the marketability of servicesis the subject of Chapter 4 and many sections on nego-tiating payment for clinical care.

Shaping the System

For those who are interested in overseeing the clinicalwork of their colleagues and shaping the health caresystem, I have included a short chapter (Chapter 5) onmanaging utilization review in managed care systems.I assume that care managers have a professional obli-gation to help patients receive what they need anddeserve, without intruding on the role of a treating cli-nician, and that the best managers manage least whileassuming responsibility for the efficient use of re-sources and the need to improve the system.

■ CONCLUSION

In addition to my own experience, this book draws onthe ideas of many of my colleagues. I have compiledthe rules, methods, ideas, and practical tips that they

xviii

devised over years of successful practice in public andprivate sector managed care systems. One goal is toshow clinicians who are unaccustomed to managingcare how to walk the line between good care and goodconservation. I hope they will discover, as I did, thatthe result is often more satisfying and effective thanthe care one would provide if resources were infinite.Another aim is to help those who know how to managecare to deal more effectively with MCO procedures,bureaucracies, and market dynamics. I will be well sat-isfied if the book helps them achieve these goals, usinglimited resources to provide better patient care.

■ REFERENCES

Bennett MI, Bennett MB: The uses of hopelessness. Am JPsychiatry 141:559–562, 1984

Glazer W: Psychiatry and medical necessity. PsychiatricAnnals 22:362–366, 1992

Gudeman JE, Shore MF, Dickey B: Day hospitalization andan inn instead of inpatient care for psychiatric patients.N Engl J Med 308:749–753, 1983

Sabin JE: Caring about patients and caring about money: theAmerican Psychiatric Association code of ethics meetsmanaged care. Behav Sci Law 12:317–330, 1994a

Sabin JE: A credo for ethical managed care in mental healthpractice. Hospital and Community Psychiatry 45:859–860, 1994b

Sabin JE: Managed care: what should we advocate for in for-profit mental health care, and how should we do it? Psy-chiatr Serv 47:1061–1062, 1996

xix

Schreter RK, Sharfstein SS, Schreter CA (eds): ManagingCare, Not Dollars: The Continuum of Mental HealthServices. Washington, DC, American Psychiatric Press,1997


xxi

ACKNOWLEDGMENTS

Most of the concepts and methods for managing carepresented in this book were developed in collaborationwith my colleagues at the Massachusetts Mental HealthCenter during many clinical discussions and case con-ferences. I owe immeasurable thanks to the “walk-insupervisors” who shared the task of providing goodtreatment with limited resources: Bill Beuscher, JohnVara, Dan Pershoneck, Anita Gerhard, Steven Kings-bury, Bob Goisman, Annette Kawecki, Ken Duck-worth, Jim Dalsimer, Elsie Freeman, and Dave Curtiss.My first mentor in this task, happily, was my wife,Mona Bennett, and my second and third mentors weremy bosses, Jon Gudeman and Miles Shore.

For the information I acquired about the inner work-ings of managed care organizations, I owe much to thecase managers and administrators at Harvard PilgrimHealth Care: Pat Resnick, Donna Peters, Jean Adams,Kathy Budreski, Jane Fairchild, Louise Dery-Wells,and Rhonda Matlack. I also received generous advicefrom clinical colleagues in the Boston professionalcommunity, many of whom have written about man-aged care: Judy Feldman, Jim Sabin, Barbara Dickey,

xxii

Michael J. Bennett (no relation), Paul Cotton, and JeffGeller, as well as my friends on the Massachusetts Psy-chiatric Society’s Managed Care Committee: AliciaGavalya, John Bachman, Joel Rubinstein, Gene Fier-man, and Greg Harris. Those who read earlier draftsof this book and offered their suggestions deserve spe-cial thanks. They include Susan Haskell, Ken Minkoff,John Bachman, Carol Nadelson, Louisa Mattson, EmmaForrest, Pat Sutherland, Nancy Cotton, Mona Bennett,Peter Bleiberg, Sallye Bleiberg, Sally Jencks, and mydaughter Rebecca Bennett. A special plaque of ac-knowledgment goes on my wall for two fellow writerswho were willing to read this manuscript more thanonce: my daughter Sarah Bennett and my sister, NaomiBennett. I also acknowledge the debt I owe to two anon-ymous American Psychiatric Association reviewers forcareful, thorough, detailed, and extremely helpfuladvice.

Finally, I am grateful to my family for the time theyinvested in this book, both directly and indirectly, will-ingly and reluctantly, and to my wife especially for herextraordinary moral compass and common sense, onwhich I never cease to rely.

1

1

MANAGING CAREETHICALLY

■ DEFINING THE ETHICAL GOAL

Our first goal, when we manage care, is to find an eth-ically acceptable compromise between two competingideals: serving the individual patient and conservinghealth care resources for the community (Sabin 1994a,1994b). If we were not responsible for conserving re-sources, we could prescribe treatments until they wereproven unnecessary, as Borenstein (1996) suggested,rather than not prescribe treatments until they wereproven necessary. But if, as Sabin argued, cliniciansshould take responsibility for the availability of care inthe community, and if availability depends on cost, wehave a duty to develop methods of practice that balancegood care with low cost. We cannot expect treatmentcosts to decrease in the foreseeable future, because men-tal illness and chemical dependence are disabling con-ditions for which no cure is in sight. Our goal is to findthe morally satisfactory middle ground between two

2

unacceptable outcomes: substandard care and wastedresources.

In accepting responsibility for resource conser-vation, we return to a traditional method of clinicalpractice. Clinicians have always factored resource lim-itations into their decision making (Schreter 1997).Without indemnity insurance, every treatment presentsa danger to our patients’ finances. Only during a 50-year period in the United States (Starr 1982), whenindemnity insurance was widely available, did the riskof resource depletion seem to disappear. In retrospect,it is clear that its disappearance was illusory and tem-porary. Except during this period, clinical practitionershave always needed to beware of depleting an individ-ual’s resources.

Patients also bear treatment costs that are nonmon-etary. In prescribing active treatment, clinicians invitepatients to invest in a process that may interfere with ordraw them away from other activities and priorities(Bennett and Bennett 1984). In managing care, clini-cians join with their patients to ask, “Do the advantagesof this treatment outweigh its negative impact on therest of your life?” The result is not “therapeutic de-spair” (Hamburg et al. 1993) but rather an intelligentreengagement in life. When we manage care, we treatpatients as “customers” who must understand the clin-ical, financial, and emotional risks and benefits of re-source decisions (Lazare et al. 1975, 1989).

In accepting the ethical value of managing care, wedo not demean other approaches, as long as their cost to

3

the patient or the community is not disproportionate totheir benefit. When resources are available, we mayelect to treat problems even though the treatments arenot covered by insurance, or we might use costly treat-ment techniques that may be helpful but have not yetproven to be cost-effective. Indeed, to practice creativelyand develop new treatment methods, we welcome suchopportunities. However, when resources are limited,we must know how to make the most of them.

■ DETERMINING BENEFIT ELIGIBILITY: UNDERSTANDING ELIGIBILITY CRITERIA

To know how well a patient is insured for treatment ofa particular condition, we need to know what con-ditions are covered and what conditions are not. Ifresources are not protected by eligibility criteria thatconfine their use to the treatment of certain conditions,they become prematurely exhausted or diluted (Bonst-edt 1992). Historically, this happened when institutionscreated to treat mental illness and mental retardationwere used to house people with a wide range of persis-tent disabilities, including persons who could not ben-efit from active treatment (Greenblatt 1975; Sederer1977). If pain and suffering were the only eligibilitycriteria for using the nonacute insurance benefit foroutpatient treatment, those resources would not lastlong (Sabin and Daniels 1994). If an insurance com-pany acquired a reputation for ignoring eligibility crite-

4

ria, its resources would be depleted by the sick patientswho selected it over other products by a process knownas adverse selection.

We expect a behavioral health insurance benefit tocover conditions that are severe, illness related, behav-ioral, and measurable. Eligibility criteria should delin-eate these conditions while separating them from othersources of mental distress. The criteria must includebut not entirely rely on DSM-IV-TR (American Psychi-atric Association 2000) diagnostic criteria, our best(though imperfect) method for defining illness. Theymust also include severe behavioral problems that donot fit well into DSM-IV-TR but are nevertheless a pri-ority for the benefit (assuming that they are treatable),such as problems that interfere with the ability to work,raise children, or develop into an adult. For acuteinpatient care, eligibility criteria must also distinguishbetween problems that are likely to respond to treat-ment and those that are not. Methods for applying theseeligibility criteria to nonacute and acute care are de-scribed in Chapters 2 and 3.

DSM-IV-TR Diagnosis

The growing use of DSM-IV-TR diagnostic criteria asa condition for benefit eligibility reflects public andprofessional acceptance of the concept of parity (i.e.,that insurance coverage for “biologically based” men-tal illness should be the same as for medical illness).The use of these criteria reflects calls in our literature

5

to give high priority, in terms of insurance benefits, todiagnosable disorders and disease (Glazer 1992). Thecriteria protect the benefit from being used for less welldefined and more prevalent forms of psychological suf-fering. As a result, from the beginning of every clinicalevaluation, we search for the signs and symptoms thatestablish a patient’s problem as a DSM-IV-TR disorder.These criteria will undoubtedly expand as research ex-tends the definition of biologically based illness.

Non–DSM-IV-TR Behavioral Problems

Certain behavioral problems that do not clearly meetDSM-IV-TR criteria for mental illness nevertheless meritinsurance coverage because they cause impairedfunction (Bennett 1996) in the critical areas of work-ing, learning, parenting, and growing up (Goodman etal. 1992). If nonacute treatment, in particular, is likely toalleviate dysfunction in these areas, it is cost-effective.

Likelihood of Improvement

The likelihood of improvement is an eligibility crite-rion for acute care coverage because most private in-surance does not cover long-term custodial care, thecost of which has traditionally been borne by the gov-ernment. This criterion excludes inpatient or residentialcare for people with long-term disabilities (such as cer-tain schizophrenic patients and behaviorally disturbedchildren), except for the purpose of acute stabilization.

6

Our job, if any doubt exists about a problem’s potentialfor improvement, is to seek evidence that a patientfunctioned at a higher level in the not-too-distant past,thus creating an expectation of recovery; derived bene-fit in the past from a similar treatment; or is likely tobenefit from a new treatment.

Benefit Exclusions

When a patient’s problem is not covered by private in-surance, we must know how to obtain other resources.These include Medicaid, Social Security disability, vet-erans’ benefits, state mental health and substance abusebenefits, and school funding for residential care.

■ DETERMINING MEDICAL NECESSITY

To develop a “medically necessary” (i.e., cost-effective)treatment plan, we match our understanding of the pa-tient’s needs against our knowledge of all availablesources of treatment and support and prescribe a com-bination that is just enough to assure recovery or stabi-lization. The needs arise from a risk of harm and otherbehavioral health problems that may benefit from treat-ment. The resources include nonprofessional supportand intermediate care programs that offer many of theacute services provided to inpatients, but at lower cost.Our plan should use no more resources than are neces-sary to achieve the goals of safety, stabilization, and, itis to be hoped, improvement. The plan should allow for

7

the possibility that more resources may prove neces-sary. It offers “good enough” treatment without luxuryor waste (Sabin and Neu 1996; Shore and Beigel1996).

Assessing Risk of Harm

We assess a patient’s risk of harm carefully because itis a major determinant of whether and how much treat-ment is needed (Lyons et al. 1997) and because thereare negative consequences to over- or underestimatingit. In general, the higher the risk, the more intensive thenecessary treatment. For example, an impulsively sui-cidal patient needs to be treated on a locked inpatientward; a patient who cannot care for himself or herselfneeds daily treatment but may not need to stay in alocked unit. When we assess risk, a patient’s diagnosisis not as predictive as information about recent and pastbehavior and the availability of support. We seek toidentify warning signs that preceded harm in the past.In the end, we must rely on personal instinct and judg-ment, regardless of how strenuously a patient assuresus that he or she will be safe.

Assessing Treatment Effectiveness and Risk of Relapse

To avoid wasting resources on ineffective treatment, wecontinually force ourselves to be objective about whethera treatment is likely to improve a patient’s condition or

8

prevent relapse (M.J. Bennett 1996; Glazer 1992). Wecannot afford to recommend a treatment for nonobjec-tive reasons, such as the fact that it makes us or our pa-tients feel less helpless, generates a positive feeling, orreduces hopelessness. We must look for evidence thatthe treatment works. To do this, we review the outcomeof old and recent treatment trials and reexamine patientmotivation. Once treatment begins, we evaluate itseffectiveness by monitoring measures of outcome. If noimprovement occurs within several weeks, we assumethat the treatment is ineffective, unless there are scien-tific data supporting the possible effectiveness of alonger treatment trial. If improvement occurs and thenlevels off, we evaluate the ability of ongoing treatmentto prevent relapse (i.e., provide a “holding operation”[M.J. Bennett 1996]) by reducing it gradually and ob-serving the results.

Assessing Nonprofessional Support

In the case of patients who do not need the safety of alocked unit, we match their acute needs to the servicesprovided by intermediate care programs, after drawingas much as possible on nonprofessional sources of sup-port such as family and friends. For instance, if the fam-ily of a disabled patient can provide around-the-clocksupport and transportation to and from treatment, thatpatient may need no more than weekly outpatient ther-apy, whereas he or she may need a partial hospital pro-gram for 8 hours per day if there is no one at home to

9

care for him or her. A growing literature shows thatsuch arrangements can be as effective as hospitaliza-tion and produce the same satisfaction in patients andtheir families (Gudeman et al. 1983; Hawthorne et al.1999; Sledge et al. 1996; Wasylenki et al. 1997). InChapter 3, I describe how to choose among commonkinds, or levels, of acute care.

■ COMANAGING WITH PATIENTS

Whenever we and our patients discuss the constraintsthat money can impose on treatment, we engage in apainful but potentially therapeutic process of assessingand accepting prognoses, delineating responsibilities,and prioritizing goals. Informing patients about theeconomic as well as clinical risks and benefits of eachtreatment or treatment change may increase their feel-ings of helplessness, but it also empowers them tomake decisions (Feldman 1992; Sabin 1992). For ex-ample, a clinician might say:

I recommend increasing your medication rapidly,because it will speed your recovery and reduce yourneed for inpatient treatment for which your annualinsurance will soon be exhausted. The increase ismore likely to cause bothersome side effects than alower dose, but I think the potential benefit is worththe risk. What do you think?

Frequently, bad news about the expected benefit oftreatment is good news about the patient’s obligation to

10

invest in it: “Recovery will take time regardless of whetheryou undergo intensive treatment.” For example, a pa-tient might be told:

Weekly outpatient treatment will probably not speedyour recovery from depression, and therefore insur-ance will not cover it. Less frequent sessions, to-gether with medication, are usually as effective. Letus try monthly sessions, and if they prove insuf-ficient, I will inform your insurance company thatmore frequent sessions are medically necessary.

Another patient might be informed:

Infrequent sessions may be all that you need. Morefrequent sessions have not done more for you in thepast and will cost much more.

Sharpening Personal Choices

In delineating the limitations of treatment, we oftenhelp patients understand the importance of their ownactions. For instance, a clinician might say to a patient:

Once detoxification is over, I recommend 24-hourresidential rehabilitation, which is covered by yourinsurance policy, but only if it appears likely tohelp. This will depend on whether you are ready toattend AA [Alcoholics Anonymous] meetings andmove into a sober house.

Another patient might be told:

11

Your insurance covers no more than a few sessionsof marital therapy each year, but these sessions willbe more effective if we can use each one to definebehavioral goals to be achieved between sessions.

Obtaining Other Resources

By forcing ourselves to consider the potential limita-tions of treatment and treatment resources, we come togrips with the need to obtain noninsurance benefits. Apsychiatrist might inform the parent of a patient:

As soon as your son’s condition has stabilized, hisinsurance will no longer cover residential treat-ment, even though he will probably not be ready toreturn home. Right away, we need to ask his schoolto fund residential treatment, reminding administra-tors that he tends to set fires and seeking supportfrom his teachers, probation officer, and outpatienttherapist.

■ WORKING WITH MANAGED CARE ORGANIZATIONS

Knowing How to Obtain Special Services

To obtain the best for our patients, we should be awarethat many managed care organizations (MCOs) provideclinical case management for frequently hospitalizedpatients and that their care managers can often ensurepayment for services that are not usually covered or

12

that are out of network, as long as these services mayprevent inpatient admission.

Obtaining Deserved Benefits

We use our understanding of both the principles ofmanaged care and the working of MCOs to obtain re-sources that our patients deserve. A treatment plan thatreflects a sound understanding of the principles ofmanaged care should elicit support from the MCO caremanagers who review or manage utilization. If it doesnot, we have a moral and legal obligation to exhaust allappeal opportunities (Wickline v. California 1986).Our appeals are more likely to be successful if insteadof venting frustration, we reason with care managersand the physician advisors who hear appeals (Green1989; Task Force on Managed Care 1993). If, afterappeals are completed, we continue to believe that ourpatients’ rights were not honored, we should advisethem that MCOs are as responsive as other organiza-tions to usual means of protest, such as seeking legalhelp or requesting assistance from politicians and exec-utives who purchase insurance. Here is an example:

Believing that a patient was at clinical risk of harm-ing herself, a clinician prepared to hospitalize herwhile presenting his reasons for doing so to an MCO’scare manager. When, to his surprise, the care managerdid not agree that hospitalization was necessary andso refused to authorize payment, the clinician wentahead with the admission while marshaling his evi-

13

dence for the appeals process and then presentingand documenting that evidence. If this process hadbeen ineffective, he would have advised his patientto seek legal advice or ask her employer to contactinsurance company executives on her behalf.

Acquiring Leverage Over Contracts

Faced with an overwhelming change in market condi-tions that has been compared to the Industrial Revolu-tion (Bittker 1985; Cummings 1995), we often find thatwe need to improve the marketability of our services orotherwise change market conditions to offset the ad-vantage that MCOs currently enjoy. We improve thevalue of our services by tailoring them to an MCO’snetwork needs or by supplying them with other prod-ucts, such as information about quality improvement,that can help them meet performance standardsimposed by overseers such as accreditors, the govern-ment, and large customers (Rodriquez 1992). We alsoenhance our services by joining with other cliniciansto provide a wider array of services. If a clinical orga-nization is sufficiently large, it may influence marketdynamics in the same way that MCOs have. Marketingour services to MCOs is the subject of Chapter 4.

■ CONCLUSION

We who practice managed care enjoy the challenge ofbalancing the needs of the individual against society’s

14

need to conserve resources. The practice has a traditionalfeel. We acknowledge an ethical responsibility to attendto the risks of either undersupplying care or wasting re-sources. In helping patients make decisions about lim-ited resources, we often find that we have helped themcome to terms with deeper limitations. In accepting lim-its, we often find ourselves accomplishing more thanwe could have otherwise.

Our skills grow to meet the goals of a managed prac-tice. We must know how to root out information thatwould establish a patient’s eligibility for his or herinsurance benefit, and we must know how to find otherresources when necessary. We must develop a keen feelfor our patients’ needs in a very short time if we are toprovide just enough services to meet them without cre-ating unacceptable risk. We must also develop a feel forthe supportive ability of family and friends if we are torely on their support without overburdening them.

The better we understand MCOs, the more effec-tive we become at advancing our patients’ rights andour own. We should know how to present evidence thatwill persuade care managers and physician advisorsthat the resources we request are well deserved. Weshould understand that a friendly demeanor is an assetthroughout the appeals process and does not precludelegal or other challenges to a decision with which wedisagree. We should regard an MCO’s needs as marketopportunities to be identified and serviced while weseek alliances that will increase our influence in themarketplace. We should assume that MCOs are an

15

imperfect administrative and fiscal tool for encourag-ing and funding the practice of managed care, an im-perfect means to a worthwhile end.

■ REFERENCES

American Psychiatric Association: Diagnostic and Sta-tistical Manual of Mental Disorders, 4th Edition, TextRevision. Washington, DC, American Psychiatric Associ-ation, 2000

Bennett MI, Bennett MB: The uses of hopelessness. AmJ Psychiatry 141:559–562, 1984

Bennett MJ: Is psychotherapy ever medically necessary?Psychiatr Serv 47:966–970, 1996

Bittker TE: The industrialization of American psychiatry.Am J Psychiatry 142:150–154, 1985

Bonstedt T: Managing psychiatric exclusions, in ManagedMental Health Care: Administrative and Clinical Issues.Edited by Feldman JL, Fitzpatrick JP. Washington, DC,American Psychiatric Press, 1992, pp 69–82

Borenstein DB: Does managed care permit appropriate useof psychotherapy? Psychiatr Serv 47:971–974, 1996

Cummings NA: Impact of managed care on employment andtraining: a primer for survival. Professional Psychology:Research and Practice 26:5–9, 1995

Feldman JL: The managed care setting and the patient-therapist relationship, in Managed Mental Health Care:Administrative and Clinical Issues. Edited by FeldmanJL, Fitzpatrick JP. Washington, DC, American Psychiat-ric Press, 1992, pp 219–230


16

Goodman M, Brown J, Deitz P: Managing Managed Care: AMental Health Practitioner’s Survival Guide. Washing-ton, DC, American Psychiatric Press, 1992

Green SA: The process of reviewing peers. Gen Hosp Psy-chiatry 11:264–267, 1989

Greenblatt M: Psychiatry: the battered child of medicine.N Engl J Med 292:246–250, 1975


Hamburg P, Stelovich S, Sabin J: Managing therapeutic de-spair. Harv Rev Psychiatry 1:238–243, 1993

Hawthorne WB, Green EE, Lohr JB, et al: Comparison ofoutcomes of acute care in short-term residential treatmentand psychiatric hospital settings. Psychiatr Serv 50:401–406, 1999

Lazare A, Eisenthal S, Wasserman L: The customer ap-proach to patienthood: attending patient requests in awalk-in clinic. Arch Gen Psychiatry 32:553–558, 1975

Lazare A, Eisenthal S, Frank A: Clinician/patient relations,II: conflict and negotiation, in Outpatient Psychiatry: Di-agnosis and Treatment, 2nd Edition. Edited by Lazare A.Baltimore, MD, Williams & Wilkins, 1989, pp 137–152

Lyons JS, Stutesman J, Neme J, et al: Predicting psychiatricemergency admissions and hospital outcome. Med Care35:792–800, 1997

Rodriquez AR: Management of quality, utilization and risk,in Managed Mental Health Care: Administrative andClinical Issues. Edited by Feldman JL, Fitzpatrick JP.Washington, DC, American Psychiatric Press, 1992,pp 83–87

Sabin JE: The therapeutic alliance in managed care mentalhealth practice. J Psychother Pract Res 1:29–36, 1992

17

Sabin JE: Caring about patients and caring about money: theAmerican Psychiatric Association code of ethics meetsmanaged care. Behav Sci Law 12:317–330, 1994a

Sabin JE: A credo for ethical managed care in mental healthpractice. Hospital and Community Psychiatry 45:859–860, 1994b

Sabin JE, Daniels N: Determining “medical necessity” inmental health practice. Hastings Cent Rep 24:5–13, 1994

Sabin JE, Neu C: Real world resource allocation: the conceptof “good-enough” psychotherapy. Bioethics Forum 12:3–9, 1996

Schreter RK: Essential skills for managed behavioral healthcare. Psychiatr Serv 48:653–658, 1997

Sederer L: Moral therapy and the problem of morale. AmJ Psychiatry 134:267–272, 1977

Shore MF, Beigel A: The challenges posed by managed be-havioral health care. N Engl J Med 334:116–118, 1996

Sledge WH, Tebes J, Rakfeldt J, et al: Day/Hospital/Crisisrespite care versus inpatient care, part I: clinical out-comes. Am J Psychiatry 153:1065–1073, 1996

Starr P: The Social Transformation of American Medicine.New York, Basic Books, 1982

Task Force on Managed Care: How to Communicate Effec-tively With Managed Care Companies When AppealingNon-certification Decisions. Washington, DC, AmericanAcademy of Child and Adolescent Psychiatry, 1993

Wasylenki D, Gehrs M, Goering P, et al: A home-based pro-gram for the treatment of acute psychosis. CommunityMent Health J 33:151–162, 1997

Wickline v California, 192 Call Ap 3d 1630, 239 Cal Rptr810 (1986)


19

2

MANAGINGNONACUTE CARE

For patients who rely on insurance to pay for nonacuteoutpatient therapy, a managed benefit offers advantagesover nonmanaged insurance plans. Without manage-ment, patients who need nonacute treatment usuallyreceive no more than a small, fixed annual maximumbenefit. Without this cap, an almost unlimited variety ofproblems and therapies would deplete the insurance re-source set aside for nonacute treatment (Olfson and Pin-cus 1994a, 1994b). A managed benefit does not need tohave fixed annual limits, because other methods are usedto conserve resources. As a result, patients can obtain anamount of outpatient treatment that depends on the kindsof problems they have and the amount of treatment theyneed. Managed coverage confirms Sabin’s (1994) ratio-nale for the practice of managed care: that limiting theuse of behavioral health resources to the medically nec-essary treatment of mental illness will ultimately im-prove the availability of care for the community.

To estimate the amount of resources to which ourpatients have access, we need to know which problems

20

are completely covered by insurance and which arepartially covered. If treatment requires more than 10sessions or so, we use a process of trial and observationto discover the least frequent treatment that will im-prove or maintain the patient’s condition. Having devel-oped a cost-effective, long-term treatment plan, we shouldknow how to present it persuasively to care managersfrom the patient’s managed care organization (MCO),persisting if necessary through the appeals process inorder to obtain the resources to which our patients areentitled.

■ DETERMINING NONACUTE COVERAGE

A managed outpatient benefit usually applies to twooverlapping types of problems for as long as patientsneed treatment, and in most cases, outpatient care forother problems is partially covered. The two problemsfor which nonacute treatment is most completely cov-ered are mental illness (both acute and persistent) andsevere behavioral dysfunction that interferes with work,education, parenting, or child development. Outpatienttreatment is covered for many life problems that areaccompanied by symptoms of mental illness such asdepression or anxiety or by dysfunctional behavior(Sabin 1996). Coverage of outpatient treatment for lifeproblems that do not involve illness or major dysfunc-tion is usually limited to a small number of treatmentsessions annually.

21

Evaluating Coverage

We establish a patient’s right to outpatient coverage byuncovering and documenting evidence of mental ill-ness and severe behavioral dysfunction. This evidenceincludes data that

• meet criteria for a DSM-IV-TR (American PsychiatricAssociation 2000) diagnosis and/or a “biologicallybased” mental illness,

• demonstrate a risk of harming self or others, or• document a major area of dysfunction.

Data gathering need not interfere with our forming a re-lationship with a patient, providing emotional support,and sharing insight. If it is hard to obtain informationin a clinical interview, we seek old records or ask forpermission to speak to friends and relatives.

Determining that many years ago, a particularpatient was admitted to the hospital or attempted sui-cide may be critical to establishing eligibility for cov-erage, as demonstrated in the following example:

Symptoms of moderate depression lasting for manyyears would not have entitled the patient to morethan monthly psychotherapy and medication visits,assuming that more intensive treatment was un-likely to improve his condition. A near-lethal suicideattempt 20 years earlier, however, justified morefrequent sessions if he was in crisis or experiencedan increase in symptoms.

22

We may establish a child’s eligibility for cov-erage of intensive outpatient treatment by uncov-ering information about severely dysfunctionalbehavior. For example:

A 15-year-old boy was brought for treatment be-cause of aggressive behavior in school and a de-cline in grades. Although he did not appear to bedepressed, insurance coverage was assured when itwas discovered that he had set fires and harmedanimals.

Comanaging With Patients

If nonacute care for a patient’s problem is not covered,we help the patient plan accordingly, much as wewould if he or she had no insurance. For instance, a cli-nician might say:

Your insurance will cover outpatient treatment foryour depression—such as medication, education, andstress management—for an indefinite period. Treat-ment for your marriage problems may also be help-ful, but your insurance will probably cover no morethan a few sessions of marital therapy, unless thetherapy seems to have an effect on your depression.

■ DECIDING HOW MUCH NONACUTE CARE IS NECESSARY

Once we have established a patient’s right to coverageby documenting the existence of a covered problem,

23

we must decide how much treatment is necessary. Ourmethod for doing so becomes more complex the longerthat treatment continues.

Meeting the Initial Need

If outpatient treatment is expected to be brief (i.e.,fewer than 10 sessions), it is simple to assume that atrial of treatment is necessary as long as it has restor-ative potential (Magellan Behavioral Health 2000). Thetreatment has restorative potential if it is listed in estab-lished treatment guidelines, has shown effectiveness inscientific studies, and has not previously failed to helpthe patient we intend to treat.

If a patient has already undergone many treatments,we want to know that the treatment we now proposecovers new ground or takes advantage of a change in apatient’s motivation or circumstances. We thereforemay need to review past records or question a formertherapist about the nature and effect of past treatments.

Determining Treatment Amount and Length

Once an initial course of treatment has proven benefi-cial, we determine how much treatment should begiven and how long it should continue, by experimen-tally reducing the frequency of treatment to the leastamount that sustains either active improvement or a“holding operation” aimed at preventing relapse (M.J.Bennett 1996). This method is similar to methods usedby general medical practitioners (Schreter 1995). It is

24

reasonable to assume that many patients continue toimprove or maintain their stability when the frequencyof treatment is reduced. To be careful, however, we alsoprepare a safety net to protect patients from potentialsetbacks if we have underestimated their needs.

To assess the effect of an experimental reduction oftreatment, we monitor objective measures such as harm-ful behaviors or “impairments” (Goodman et al. 1992)whenever possible. These measures include symptoms,level of functioning, level of risk, and the frequency andseverity of episodes of behavioral dyscontrol. Reducingthe intensity of treatment may involve changing bothfrequency and modality (e.g., switching from weeklyindividual therapy to monthly group therapy).

Comanaging With Patients

The discussions we have with our patients about thepotential benefit of outpatient treatment often help us toaddress the limitations of such treatment and the im-portance of accepting whatever component of painfulproblems we cannot control (Bennett and Bennett 1984).For instance, a clinician might say:

When do you feel we should meet next? My ownopinion is that you are doing better, so I wonder ifwe need to meet more than once a month. You seemto use therapy well, but you need time to makechanges, and monthly treatment may be just as effec-tive as weekly. If it is not, I will show your managedcare company that you need more frequent sessions.

25

A depressed patient might be told:

Let’s stop psychotherapy and see if it makes a dif-ference. You haven’t fully recovered from depres-sion, but that does not mean that you need or willbenefit from psychotherapy. Symptoms of depres-sion often take a long time to improve, regardless ofpsychotherapy, and you have good coping skills.You will continue to need periodic psychiatric visitsfor medication and support. If your symptomsworsen, I will show your insurance company thatyou need more treatment.

A parent of a patient might hear:

Psychotherapy for your child’s behavior problemsis covered by insurance, but much depends on howwell it seems to work. We need to assess effective-ness as we go along, understanding that managedinsurance will continue to cover treatment only if itappears to be achieving its goals.

■ OBTAINING OUTPATIENT BENEFITS FROM MANAGED CARE ORGANIZATIONS

Gaining Access to a Company’sSystem of Care

Knowing that MCOs must provide insured patientswith timely and local access to nonacute care, we shouldenlist an MCO’s help when an outpatient referral is

26

hard to obtain. If an MCO’s network cannot supplyneeded services, we can expect its care managers toarrange a timely, nearby referral and payment forout-of-network services if necessary. When faced withpatients who have had multiple admissions and are un-likely to be stabilized with available nonacute treat-ments, most companies will also fund intensive out-patient treatments, such as home-based care, or makeother arrangements to improve stability and preventreadmission.

Responding to Reviews

When we provide relevant clinical information in out-patient treatment reports, MCOs seldom question ouroutpatient treatment decisions, unless we prescribe in-tensive psychotherapy for long periods. If we do pre-scribe in this way, we need to document both a severelevel of dysfunction and a continual effort to stabilizeour patients with the least amount of treatment possi-ble. By providing only relevant information to MCOs,we improve communication, save time, and minimizedisclosure of private patient information. Knowing thatan MCO may examine a patient’s chart as part of anappeals process, we document information there aswell as in outpatient treatment reports. The followingexamples contain information relevant to resource man-agement only:

Need continuing weekly sessions for 47-year-oldman, diagnosis major depression, one prior ad-

27

mission and major suicide attempt, in crisis nowbecause of job jeopardy; suicidal ideation presentand worse than baseline. [This describes a coveredproblem, and the possible need for admission justi-fies frequent sessions.] Will need less frequent ses-sions once stabilized.

Need 8 monthly sessions for 32-year-old woman,depressive feelings but no risk of harm, no past ad-missions or suicide attempts, no dysfunction, re-ceiving meds. [This describes a covered conditionwith no need for frequent sessions.] She wants towork on reducing stress in relationships. [The pa-tient will be entitled to no more than a minimumbenefit for treatment to reach this goal.]

Need 8 monthly sessions for 45-year-old man withalcohol dependence, sober for a year, attendingmeetings, seems to feel more prone to relapse ifseen less often than monthly. [This documentsthat the treatment is the least intensive needed formaintenance.] May require more sessions if a crisisarises.

Changing to Unmanaged Treatment

If patients wish to pay for treatment of a problem thatis unlikely to be covered under a managed care benefit,we may nevertheless request a review to protect our-selves from a potential conflict of interest. For exam-ple, a patient might be informed:

28

Treatment of your relationship problem is unlikelyto be covered by insurance, but I will send them areport and see what they say. If they refuse to coverthe treatment, you will need to pay me out of yourown pocket if you wish to continue.

Understanding Denials and Making Appeals

If an MCO care manager refuses to authorize paymentfor our treatment plan, our first task is to determinewhy. Misunderstanding, the most common cause ofdenials, occurs when essential information is omitted,written illegibly, not read, or upstaged by lurid detailsirrelevant to resource management. Did we describeevidence of the patient’s having a mental illness or se-vere behavioral problem? Did we describe an effort tofind the least intensive treatment that is effective?

In addition, requests for coverage are often deniedwhen a statement is made that reflects nonobjective as-sumptions about the effectiveness of treatment. Thefollowing is an example:

This patient needs a second year of weekly psycho-therapy because she continues to have severe de-pression with flashbacks to childhood trauma.

It is not objective to assume that intensive treatmentwill be effective if it has not improved a patient’s symp-toms after a year. Perhaps the clinician’s recommenda-tion is driven by a desire to alleviate suffering, ratherthan by a rational assessment of what treatment can be

29

expected to accomplish. An objective recommendationfor intensive treatment includes evidence that the treat-ment is needed to maintain a patient’s stability. Suchevidence is presented in the following statement:

This patient needs weekly psychotherapy becauseshe continues to have severe depression and re-cently became suicidal when the frequency was re-duced.

We can help patients advocate for themselves if itappears that an MCO’s internal appeals system has letthem down. If they have a good case, they are likely toattract support from people who might influence anMCO’s decision, such as employers, legal advocates, orlocal political representatives.

■ CONCLUSION

Managing nonacute care allows us to provide more re-sources to outpatients who need them than would bepossible with an equally large, unmanaged resource.Although it is always hard, as clinicians, to limit treat-ment for patients with partially covered or uncoveredproblems or to reduce the intensity of treatment for suf-fering patients who believe they need more, we cannevertheless do much to protect patients from un-dertreatment while taking satisfaction in the greateravailability of care for some of our sickest patients. Inaddition, we discover that a discussion about limited

30

treatment coverage often spurs patients to take more re-sponsibility for managing their problems. It also causesthem to examine whether treatment, even unconstrainedtreatment, is likely to achieve all their goals.

Until the literature on long-term intensive treatmentsshows that they are more effective than less frequent,long-term maintenance treatments, we cannot justifyusing the relatively large amounts of resources they re-quire. As research uncovers a biological basis for anincreasing number of behavioral problems, however,we can expect coverage for outpatient treatment to be-come more inclusive.

■ REFERENCES




Goodman M, Brown J, Deitz P: Managing Managed Care: AMental Health Practitioner’s Survival Guide. Washing-ton, DC, American Psychiatric Press, 1992

Magellan Behavioral Health: Medical Necessity Criteria.Magellan Behavioral Health, 2000, p 22

Olfson M, Pincus HA: Outpatient psychotherapy in theUnited States, I: volume, costs, and user characteristics.Am J Psychiatry 151:1281–1288, 1994a

31

Olfson M, Pincus HA: Outpatient psychotherapy in theUnited States, II: patterns of utilization. Am J Psychiatry151:1289–1294, 1994b

Sabin JE: A credo for ethical managed care in mental healthpractice. Hospital and Community Psychiatry 45:859–860, 1994

Sabin JE: Managed care: getting managed care organizationsto cover extended psychotherapy for patients with person-ality disorders. Psychiatr Serv 47:365–366, 1996

Schreter RK: Earning a living: a blueprint for psychiatrists.Psychiatr Serv 46:1233–1235, 1995


33

3

MANAGING ACUTECARE

The cost of acute care is high and mounts up quickly.When decisions are made at the time of a crisis evalua-tion or during acute treatment, there is a strong possibil-ity of conserving resources. This conservation preventsinsurance premiums from increasing and thus improvesthe availability of care to the community (Green 1989;Sabin 1994). The first step we take to preserve acute careresources is to screen out uncovered treatments, such aslong-term custodial care, and find other resources topay for them. The second step is to find the least costlycombination of nonprofessional support and profes-sional treatment that will stabilize the patient. We arelucky if we can take advantage of intermediate careprograms that offer some but not all acute services pro-vided by inpatient programs, at less cost (Gudeman etal. 1983; Schreter et al. 1997). Not unexpectedly, man-aged care organizations (MCOs) monitor our acute caredecisions closely and frequently because of their effecton resources. We should know how to justify our treat-ment plans, pursuing appeals if necessary.

34

■ DETERMINING ENTITLEMENT TO ACUTE BEHAVIORAL HEALTH CARE

We should know how to screen out problems for whichacute care is usually not covered, and we should alsoknow how to obtain other resources for the neededcare. MCOs generally do not cover long-term custodialcare for persistently disabled patients, acute incar-ceration for people who cannot live independently forreasons other than mental illness, and long-term resi-dential treatment for children with behavioral prob-lems.

Increasingly, crisis centers perform a screeningprocess that formerly took place after admission (Allen1996). Finding resources for problems not covered re-quires ingenuity, political skills, and a knowledge ofalternatives. For example, separate resources may beallocated for patients with certain disabilities, homelesspatients, mentally retarded individuals, patients withpersistent mental illness, veterans, and patients withdual diagnoses (mental illness and chemical depen-dence). Resources were found or identified for the fol-lowing three individuals:

A homeless man who needed shelter presented foradmission but did not appear to have a mental ill-ness or want to stop drinking. Noting that he wasa veteran, crisis clinicians gave him the address ofa local Veterans Affairs–sponsored shelter andcoached him on its access requirements.

35

No state-funded community beds were available fora schizophrenic patient whose parents were grow-ing too old to care for her. Knowing that state ser-vices were more abundant where her brother lived,the patient’s clinician advised her to move in withher brother and establish residency in that area, andthen apply for state benefits.

Overwhelmed parents wanted to hospitalize theirabused 6-year-old daughter because they could notprotect her from her older brother. She was not oth-erwise at risk of harm. A clinician refused to admither and instead arranged an emergency evaluationof the brother by the state’s department of socialservices.

■ DETERMINING MEDICAL NECESSITY OF ACUTE CARE

Choosing Levels of Care

In fashioning the most cost-effective acute care plan,we must provide patients with all the treatment they re-quire, but no more than is necessary. A patient’s needfor safety is the first consideration, both because itdetermines how intensely staffed a treatment programmust be and because mistakes may be dangerous. Anintensive outpatient program (IOP) that offers therapyseveral days a week for several hours a day is said toprovide a low level of care. An inpatient program withlocked doors, seclusion, restraint, and 24-hour nursingand psychiatric services offers a high level of care. In

36

between are residential treatment centers (24 hours butwithout many nursing or psychiatric services) and par-tial hospitalization programs (PHPs; treatment servicesfor 4–8 hours at least 5 days a week). The right level ofcare to choose is the lowest one that ensures a patient’ssafety and recovery or stabilization. Before finalizingour choice, we assess the availability of nonprofes-sional support (Schreter 2000) to determine whether aless intensive level of care might be adequate.

High Risk or Intense Medical Need

We have but one choice—inpatient treatment—when pa-tients are at high risk of harming themselves or others(Lyons et al. 1997) and thus require a locked setting,24-hour care, and intensive psychiatric intervention. Ifin doubt, we err on the side of safety. Inpatient care isalso necessary for patients who require around-the-clock nursing and medical care. Patients who need thishighest level of care include those who may act impul-sively to harm themselves or others, have unstable med-ical problems, or physically resist attempts to helpthem.

We do not want to waste resources by admitting apatient for inpatient care who is not really at risk ofharm. If an initial evaluation leaves us uncertain abouta patient’s need for safety, we lose no time in seekinginformation from old records, family, friends, and priortherapists about risk of harm, and we do not stop untilwe have exhausted potential sources of information,run out of time, or uncovered definitive information.

37

Most states grant us the legal right, in emergency situ-ations, to override a patient’s refusal to consent to thisinformation gathering, as demonstrated in the follow-ing example:

A depressed patient denied being suicidal and or-dered an evaluating clinician not to speak to hisfamily. Following state law, the clinician ignoredthis directive, spoke with the family, and discov-ered that several years previously, the patient hadmade a major suicide attempt while experiencingsimilar clinical symptoms. The clinician admittedthe patient.

Subacute Risk

Once we decide a patient does not need the protectionof an inpatient unit, we have several options to con-sider. Usually, the conditions that require acute care butnot admission involve behavior that presents a gradualrisk to a patient’s safety or prevents treatment, such asan inability to get out of bed, medication noncompli-ance, self-harmful urges when alone, unhealthy eatingbehaviors, and drug use (Goodman et al. 1992). If, in aneffort to preserve resources, we prescribe a level of carethat is insufficient to arrest a patient’s decline, we canusually correct the referral in a short time without en-dangering his or her safety. Indeed, unless the rightlevel of care is obvious, the mandate to conserve obligesus to try a lower level of care before deciding that ahigher one is necessary. Consider the following:

38

An anorexic patient who was not at risk of harmwas losing weight despite weekly outpatient treat-ment. Because she exercised compulsively at allhours, it was unlikely that any treatment less inten-sive than residential treatment could help her.

An alcoholic patient experienced severe cravingsafter recovering from detoxification. It was un-likely that any treatment less intensive than resi-dential treatment would allow him to establish hissobriety.

Availability of Nonprofessional Support

The more support a family can provide, the greater thelikelihood that a less intensive level of care will ac-complish what would otherwise require a more inten-sive one. Is there someone at home who can keep aneye on the patient all day, evenings only, all weekend?Can someone drive the patient to and from a treatmentprogram? Can someone ensure that the patient takeshis or her medication? A plan that relies on family sup-port will work as well as, or better than, one that doesnot (Wasylenki et al. 1997). For instance, if family orfriends can provide overnight support and trans-portation, a daily PHP may be as effective for a patientas inpatient care. Obviously, having a family assumemore responsibility than it can bear will interfere withthe patient’s recovery and bring pain and hardship toothers.

39

Changing to Lower Levels of Care

Usually, no more than one or two problems determinea patient’s need for a particular level of care; as soon asthese improve, the patient can be stepped down to a lessintensive level of care (Bennett 1996; Glazer 1992).For most inpatients, the problem that necessitates thislevel of care is an immediate risk of harm. When we be-lieve they are safe, they can usually be discharged toless intensive care. For most patients in residentialtreatment centers, the problem is a harmful behaviorthat will recur if they are not in a 24-hour program; ina PHP, it is an inability to tolerate a day alone withoutdeteriorating. The following are two examples:

When a psychotic, suicidal woman no longerseemed likely to harm or endanger herself when leftalone, she was stepped down to a PHP. When staffthought she could keep herself safe and occupied athome but close medication monitoring was stillneeded, she was stepped down to an IOP. She wasdischarged to outpatient treatment when her familycould ensure medication compliance.

An alcoholic patient with severe withdrawal symp-toms and cravings was stepped down from inpatientdetoxification to residential treatment as soon as hismedical condition was stable. He was discharged toan IOP as soon as his cravings stopped and sober sup-ports seemed established, and he left the IOP for lessintensive outpatient treatment when he had a scheduleof AA [Alcoholics Anonymous] meetings and a spon-sor. If he had not been interested in sobriety, or if it

40

had appeared unlikely that he would benefit fromtreatment, he would have been discharged to outpa-tient treatment shortly after withdrawal was complete.

Administering Active Treatment

If no improvement occurs for several days, we usuallyhave more reason to change or combine treatments thanto wait and observe. Changing or combining treatmentsduring acute care is more likely to speed the stabiliza-tion of risk and the relief of symptoms. If such a strategyalso causes more side effects, leaves diagnostic ques-tions unanswered, and raises doubts about which treat-ment or dose is most effective, these problems can beresolved later. This shotgun approach is also a hallmarkof acute medical interventions. Here is an example:

When a suicidally depressed inpatient failed to re-spond after 3 days of treatment with an antidepres-sant, his physician added a lithium booster and,2 days later, a second antidepressant. The physicianknew from the start that the first antidepressantwould probably not be effective until it had beengiven for more than 3 days; however, by covering hisbets with other interventions, he increased the likeli-hood of rapid stabilization. Later, during nonacutetreatment, he could simplify the interventions and de-termine whether more than one was really necessary.

Preparing Plan A and Plan B

If we expect to exhaust active treatment options for apatient in the near future, we should begin searching for

41

a custodial care resource at once and try to develop aplan B in case the first plan fails. We should seekMedicaid, disability benefits, state services, countyeducational benefits, veterans’ benefits, or a financialcommitment by a family member. The two cases pre-sented here illustrate this approach:

A psychotic, suicidal woman failed to respond tothree medication trials over 4 weeks. Staff mem-bers recommended electroconvulsive therapy ortreatment with clozapine. At the same time, theyfiled an application for admission to a state hospitalin case these treatments did not help.

After a series of medication trials, staff membersbelieved that a 13-year-old inpatient was unlikely tobecome less aggressive or disorganized in the nearfuture, and yet returning home would probably re-sult in relapse. Together with his parents, they askedfor court supervision and money from his schoolboard for referral to a therapeutic school. They alsotrained his parents in behavior management, assum-ing that he would need to stay at home until a bed ina residential treatment center became available.

Comanaging Acute Care With Patients

Discussions about resource management of acute careoften correct patients’ misconceptions and help themplan realistically for the long term (Bennett and Bennett1984). Many patients assume that the more intensive thecare, the more rapid the cure. Believing this, they are

42

eager to invest more effort and, if necessary, more moneyover the short term to achieve faster and strongerimprovements in their mental health. In a discussion ofmedical necessity, they are invariably informed thatmost acute behavioral health problems tend to be recur-rent and may require long-term treatment. There is noevidence that extending acute care can hasten recoveryor prevent relapse. Although initially disappointing, thisnews helps patients manage treatment and resourcesmore effectively. For instance, a clinician might say:

Although you continue to feel depressed, I recom-mend discharge. Staying in the hospital will not speedyour recovery, and discharge will help to preserveyour benefit in case of relapse. To be safe, I want youto stay with your family for a few days and call thecrisis worker if you feel your safety is not secure.

Another patient might be told:

A longer hospital stay will not reduce your chanceof relapse, so the more time you spend outside thehospital, the better.

■ OBTAINING ACUTE CARE BENEFITS FROM MANAGED CARE ORGANIZATIONS

Gaining Access to Acute Care and Aftercare

Because MCOs are care systems as well as insurers,they are responsible for correcting access problems that

43

prevent patients from receiving the acute care they de-serve. If a medically necessary service is unavailable,MCO care managers will usually find and arrange al-ternatives, paying for out-of-network services if nec-essary. If a service that is not usually available willprevent readmission or speed discharge, they will findand fund it. Here is an example:

After a patient was readmitted to the hospital twicebecause of noncompliance with treatment, an MCO’scare manager found and arranged payment for homecare and reduced the patient’s copayment to provideincentive for him to attend outpatient therapy ses-sions.

Undergoing Review

The sooner we secure an MCO’s commitment to payfor acute care, the less likely we are to discover that theMCO has rejected a large claim, leaving the problem ofpayment to our patients and ourselves. For this reason,we seek speedy review of acute care cases and docu-ment our interactions. We secure this commitment, orauthorization, from a clinical care manager (not a clerk)through concurrent review. If the MCO’s care manageris unwilling to authorize our proposed treatment, andif we continue to believe that it is medically necessary,we must appeal at all available levels by requesting ex-pedited reviews with physician advisors. Wheneverpossible, we ask for concurrent review and avoid theprocess of retrospective review, in which authorization

44

is suspended until the MCO receives and reviews thepatient’s complete chart. We do not let resentment overthe burden of the review process interfere with our goal,which is to protect our patient’s interests and our own.

Answering the Unasked

Although we expect an MCO’s care managers to respondpositively to a well-managed treatment plan, we alsocommunicate carefully to avoid misunderstanding. Aneffective way of organizing and presenting informationis to answer questions we ask ourselves about resourcedecisions. Deleting irrelevant information reinforces ourfocus.

Entitlement. If a patient’s condition might not becovered by insurance, we ask ourselves: “What is itabout this patient’s problem that entitles him or her tothe insurance benefit?” A response might be one of thefollowing:

The patient’s admission was court ordered, but forclinical, not administrative, reasons; he was clearlymanic and unable to care for himself.

The nursing home no longer wants to care for thispatient, but for reasons that are treatable. He re-cently started to hit staff members despite appropri-ate administration of medications as needed.

Level of care. Whenever we consider the medicalnecessity of a certain level of care, we ask ourselves:

45

“Would a less intensive level of care be just as effec-tive?” We might respond:

If this depressed patient were in anything less thana PHP, she would not be able to get out of bed andfeed herself.

Goal. When a patient has many severe problems, weask ourselves: “What is the one thing that needs to changeif this patient is to be stepped down to a less intensivelevel of care?” A response might be the following:

If this patient were no longer assaultive, we couldsend her back to her nursing home.

Restorative potential. If we fail to observe improve-ment, we ask ourselves: “If this treatment did not workin the past, why should it work now?” or “If this treat-ment does not work now, what then?” Consider theseanswers:

This self-mutilating patient needs a trial of inten-sive behavioral outpatient therapy that is differentfrom the therapy to which she failed to respond inthe past.

If this psychotic patient does not respond to thismedication, there are several others to try that havenot been used before.

Safety. Whenever safety is a prime determinant ofthe level of care, we ask ourselves: “What evidence

46

suggests that this patient would be unsafe with less in-tensive treatment?” Here is one response:

Although this depressed patient has assured us thathe will not harm himself, he needs to be admitted;he made a serious suicide attempt 10 years ago, isunreliable, and has access to guns.

Nonprofessional support. Whenever we determinethat a patient might be safe outside a locked unit, weask ourselves: “Can support from the patient’s familymake a difference in the level of care that he or sheneeds?” We might respond:

This depressed patient needs a daily IOP or a visit-ing nurse, because there is no one at home to givehim his medications.

Risk of relapse. Whenever a patient does not appearto require the level of treatment he or she is currentlyreceiving, we ask ourselves: “What evidence suggeststhat discharge or step-down (i.e., transfer to a less in-tensive level of care) would precipitate relapse?” Twoexamples of responses follow:

This manic patient is stable but would not continueto take his medication if he left the PHP.

This alcoholic patient no longer has cravings butneeds additional residential care because he doesnot yet have a sober residence to return to.

47

Appealing

If an MCO’s care manager believes that the treatment werecommend should not be covered but we disagree, wehave a moral and legal obligation to appeal the care man-ager’s decision (Wickline v. California 1986) and protectour patients’ safety (Bursztajn et al. 1991), regardless oftheir insurance status. We should not be surprised if caremanagers sometimes disagree with us. They often receivemisinformation from program clinicians who are unfamil-iar with our patients. They may have read contradictorystatements in a patient’s record. They may feel pressuredby their company to “lower the numbers” and reduce ser-vice utilization. Whatever their reason for disagreeing, weshould be prepared and respond professionally.

Once we recognize early signs of disagreement, wetry to understand the reasons for the disagreement. Thefirst sign of an impending denial or disagreement isa care manager’s request for an “MD to MD review.”We probe the care manager’s reasoning to uncover amisunderstanding based on incomplete or misleadinginformation. We try to correct misunderstandings ver-bally and in the patient’s record, which will be used inthird- and fourth-level retrospective appeals, if thesebecome necessary. Here is an example:

On learning that a care manager had requested anMD to MD review because an inpatient no longerhad suicidal ideation, a clinician marshaled evi-dence demonstrating that the patient’s risk of harmremained high.

48

If, after exhausting all appeals, we continue to be-lieve that our patients deserve coverage they have notreceived, we advise them on other legitimate methodsby which they may assert their rights, such as asking forlegal help from or advocacy by an employer or locallegislator.

■ CONCLUSION

We accept the challenge of practicing acute care, know-ing that our decisions can save or waste large resourcesin a short time. We need to balance an intense com-mitment to patients’ safety with an aggressive effort toavoid waste. This begins with screening out uncoveredtreatments and finding other resources for them. It con-tinues with a careful risk evaluation that prevents in-patient resources from being used for unnecessaryinpatient care while protecting patients who are at riskof harm. It impels us to use rapid shotgun therapywhenever the benefits outweigh the risks; to evaluateand negotiate family support, which may permit the useof a less intensive level of care; and to transfer patientsto less intensive levels of care as soon as possible. Weshould hold MCOs responsible for helping patientswhen the care system is slow to respond, secure autho-rization for services in advance, communicate effec-tively with MCOs, and help patients assert their rightsif they are unfairly denied.

As we improve the management of acute care in-surance resources, we expose problems that unman-

49

aged insurance tended to obscure, such as the lack ofcoverage of long-term custodial care for those with per-sistent illness and of long-term residential treatment forchildren with severe behavioral problems. If our effortsreduce funding for these services, it is because theydrew on resources that were not meant for them and so-ciety has yet to determine how to pay for them. Ourhope is that the tight accountability for resources thatmanaged care imposes will spur society to acknowl-edge the existence of large coverage gaps, encourage itto allot new resources, and assure it that these resourceswill be managed efficiently. As clinicians working withindividual patients, we often find that weighing costsforces us to face limitations and devise realistic solu-tions. On a societal level, we hope such considerationwill do the same.

■ REFERENCES

Allen MH: Definitive treatment in the psychiatric emergencyservice. Psychiatr Q 67:247–262, 1996



Bursztajn H, Gutheil TG, Cummins B: Legal issues in in-patient psychiatry, in Inpatient Psychiatry: Diagnosis andTreatment. Edited by Sederer LI. Williams & Wilkins,1991, pp 379–406


50

Goodman M, Brown J, Deitz P: Managing Managed Care: AMental Health Practitioner’s Survival Guide. AmericanPsychiatric Press, Washington, DC, 1992



Lyons JS, Stutesman J, Neme J, et al: Predicting psychiatricemergency admissions and hospital outcome. Med Care35:792–800, 1997

Sabin JE: A credo for ethical managed care in mental healthpractice. Hospital and Community Psychiatry 45:859–860, 1994

Schreter RK: Alternative treatment programs: the psychiat-ric continuum of care. Psychiatr Clin North Am 23:335–346, 2000

Schreter RK, Sharfstein SS, Schreter CA (eds): ManagingCare, Not Dollars: The Continuum of Mental HealthServices. Washington, DC, American Psychiatric Press,1997

Wasylenki D, Gehrs M, Goering P, et al: A home-based pro-gram for the treatment of acute psychosis. CommunityMent Health J 33:151–162, 1997

Wickline v California, 192 Call Ap 3d 1630, 239 Cal Rptr810 (1986)

51

4

MARKETING TO MANAGEDCARE ORGANIZATIONS

Because of the oversupply of behavioral health ser-vices in many urban areas and the high cost of main-taining a large network, managed care organizations(MCOs) may have little incentive to contract with oroffer reasonable reimbursement to those who wish totreat their enrolled patients. If, however, we are willingto explore the needs of MCOs, market our services, andtake advantage of other opportunities to influencemarket conditions, we can increase the value of ourservices and our ability to negotiate an acceptable con-tract.

■ PRESENTING CREDENTIALS

Responding to an Interview

Our first task in marketing our services is to show anMCO that we know how to practice managed care anduse a managed insurance benefit. To do so, we seek in-terviews with MCO administrators, knowing that almost

52

any clinical topic will afford an opportunity to displaymanaged care experience. At the same time, we avoiddescribing interests, experiences, or modes of prac-tice that managed care companies may regard asinterfering with our ability to work with them. Fol-lowing are questions we may encounter, responsesthat demonstrate experience with the practice of man-aged care, and responses that may give the oppositeimpression.

What Conditions Do You Treat?

Knowing that insurance resources are set aside for thetreatment of certain conditions, we focus on the ser-vices we offer for patients with those conditions. Weunderstand that using an insurance benefit to treat prob-lems for which it was not intended interferes with itsprimary mission. As noted in Chapter 1, covered con-ditions include mental illnesses and behavior that inter-feres with a patient’s ability to work, learn, parent, orgrow up. A response to a question about conditionstreated might be “I provide outpatient services for pa-tients with mental illness or dysfunction at work orschool or in parenting” or “Our day hospital servicesare for stabilizing patients with severe depression,schizophrenia, and/or self-harmful behavior.” We shouldnot imply that we would use the insurance benefit totreat uncovered or low-priority conditions, as the fol-lowing statement suggests: “We serve patients with lowself-esteem, lives of isolation, and unfulfilling relation-ships who make poor choices.”

53

How Do You Treat Depression?

We rely on a scientific, medical model of illness (Glazer1992) when it comes to evaluation and treatment of de-pression. For example, we might say: “We use a structuredintake to assist us in making a diagnosis and decidingwhether a psychiatric evaluation is needed.” We avoid im-plying that we use psychotherapy as a substitute for a di-agnostic evaluation, as the following response suggests:“We try to address issues that may cause depression. If thisis ineffective, we arrange for a psychiatric evaluation.”

What Do You Do for Patients Who Continue to Require Custodial Care After All Acute Treatment Opportunities Have Been Exhausted?

We understand that most managed insurance benefitsdo not cover treatment for certain patients who needcustodial care, as noted in Chapter 1, and we are expertat finding other resources for them. For example, wemight respond: “If a patient in our program needs long-term custodial care, we know how to gain access to hisentitlements and move him to a more appropriate set-ting. We have excellent relationships with state casemanagers who screen patients to determine eligibilityfor long-term programs.”

We would not want to imply ignorance of coveragelimits and methods for dealing with them, as the fol-lowing statement does: “We have a rich array of long-term residential services that can support patients if therecovery period is prolonged.”

54

How Do You Treat Patients With Posttraumatic Stress Disorder or Borderline Personality Disorder or Patients Who Have Made Repeated Suicide Attempts?

When we treat persistent, long-term conditions, we dis-tinguish between the goal of improvement and the goalof maintenance and thus rely on intensive treatment nomore than necessary. We might say: “We provide long-term, maintenance treatment for patients with per-sistent disabilities, using relatively infrequent sessionsexcept when a crisis necessitates more intensive inter-vention.” We should not appear ignorant of the princi-ples of medical necessity described in Chapter 1, as thisresponse suggests: “We can continue to provide weeklylong-term treatment for patients who have failed to re-spond to short-term interventions.”

Do You Provide Long-Term Outpatient Treatment?

We regularly assess the outcome of treatment to assureourselves that we prescribe no more than necessary toimprove or maintain a patient’s condition. We are clearabout our goals, such as restoring a baseline level offunctioning (Sabin and Daniels 1994), and are familiarwith “modular” and standardized treatments (Sabin1996). A response might be “We teach patients how toreduce and manage self-harmful behaviors, initially withan intensive educational program and later with main-tenance groups that use cognitive-behavioral and 12-step models.” We should not appear to endorse goalsrooted in subjective feeling or psychotherapeutic pro-

55

cess, as the following statement implies: “We help pa-tients heal from old traumas by helping them get intouch with painful feelings in the context of a support-ive therapeutic relationship.”

How Does Your Program Help Its Clinicians Manage Care?

Treatment programs that manage care most effectivelyempower their senior managers to monitor and manageresources, and administrative tools are provided for do-ing so (Schreter 1997, 1998). We may organize clini-cians into peer groups that meet regularly to review themedical necessity of ongoing cases (Pomerantz et al.1995), or we may have a senior clinical administratorreview cases that use the most resources. We should notimply that a program is more expert at communicatingwith MCOs than at practicing managed care, as thefollowing response does: “Our clinicians are experi-enced with managed care, and a special case manageris available to conduct reviews with your company’scare managers.”

How Do You Schedule Appointments?

Because we often determine the timing of a patient’snext appointment during the course of a treatment ses-sion, we seldom schedule patients into regular weeklyslots. A clinician might say: “I keep several hours openevery week to manage last-minute crises. Otherwise,I decide when to schedule a patient’s next appointment

56

after I see how well he or she is doing.” We should notimply that we slot patients into preset weekly appoint-ments.

How Do You Ensure Appropriate Follow-Up When Patients Leave Your Care?

Knowing that acute care patients often move rapidlyfrom one intermediate care program to another, we de-velop methods of communicating about them that “passthe baton smoothly” (Sabin 1998). A response mightbe: “We fax our treatment recommendations to the pa-tient’s outpatient clinician on the day of discharge andprovide crisis support until the patient’s first appoint-ment. We also routinely fax copies of our evaluations tothe patient’s primary care provider.” We should not ap-pear to rely on long stays to ensure safe transitions, asthe following statement suggests: “We do not dischargepatients until we see how they do after a series of passesand a visit with their outpatient clinicians.”

Avoiding Profiles

Many MCOs deny network membership to clinicianswho have certain interests, skills, or other characteris-tics that the MCOs believe will interfere with the ap-plicants’ ability to practice managed care. Wishing topresent our strength in managing care and avoid pre-judicial judgment, we focus our presentation on topicsrelevant to managing care and do not discuss other topics.It helps to obtain information about an MCO’s aver-

57

sions from an MCO care manager or a clerk in the net-work development department or to deduce them byreading between the lines of a screening form. For ex-ample, an MCO may have negative prejudices about

• part-time practice, because it makes clinicians lessavailable for referrals and emergency coverage.

• teaching-hospital practice, because it encouragesmore costly care and argumentativeness.

• the lack of a hospital affiliation, because it predis-poses clinicians to prefer working with patients whodo not have a DSM-IV-TR (American PsychiatricAssociation 2000) diagnosis.

• psychoanalysis and other intensive treatments, be-cause practitioners believe in the superiority of thesetherapies and will draw on the insurance benefit topay for them.

■ MEETING AN MCO’SUNADVERTISED NEEDS

Even when an MCO seems satisfied with its networkand has closed its doors to applicants, its clinical man-agers often seek services that the network cannot sup-ply and for which they would willingly contract. Ifasked, they are eager to share information about theseneeds, which they are responsible for addressing. Fol-lowing are questions that survey the most common ser-vice needs that might motivate an MCO to seek newcontracts or sweeten old ones.

58

Providing Regional and Special Clinical Services

Are there specialty services that an MCO believes areundersupplied either throughout its network or in localgeographic regions? Being able to provide a neededservice in an underserviced region increases the valueof our services to an MCO. Special services include pe-diatric and geriatric treatment; behavioral treatment(such as cognitive-behavioral therapy) for patients atrisk of harming themselves; treatment for patients witheating disorders or obsessive-compulsive disorder; andtreatment for victims of rape or abuse.

Offering Other Special Services

Does the company need handicapped-accessibleoffices, or clinicians with certain language or culturalcompetencies? Does it need clinical groups that canprovide treatment on weekends and holidays?

Improving Quality

Does an MCO need help to meet performance stan-dards that will affect its reputation, accreditation, orearnings? MCOs must meet a growing number of per-formance standards imposed by accreditors, such as theNational Committee for Quality Assurance (2001); bynational industry organizations that benchmark quality,such as the American Managed Behavioral HealthcareAssociation (American Managed Behavioral Health-

59

care Association 1996); and by large insurance pur-chasers, which may award bonuses or penalties basedon an MCO’s performance.

Does an MCO need data about services or qualityimprovement that it cannot easily collect itself? Does itneed a quality improvement study conducted—one thatit cannot easily perform itself but for which it can takecredit? Clinicians working in institutions and programsare often better equipped than a managed care companyto do quality improvement studies. For accreditation, acompany must show a record of quality improvement,and it can satisfy this requirement by delegating re-sponsibility to its network providers. We increase thevalue of our services if we can devise studies that helpa company gain accreditation.

As network performance standards become moresophisticated (Blumenthal 1996; Brook et al. 1996),companies become more willing to contract for theproducts they need. For example, a program was unableto attract an MCO contract, despite offering excellentbut standard services, until it marketed its ability toshare data from a quality improvement program that re-duced medication side effects through examination ofprogress notes associated with medication changes.

Appearing at the Hour of Need

When is an MCO most likely to need our services? Wemay take advantage of the increased market demandfor our services that occurs when an MCO first enters a

60

region and must assemble a network in very little time.This opportunity also occurs when an MCO discoversthat it must enhance its network to meet accreditationstandards, and accreditation is only a year away.

Demonstrating Need

If we identify an undersupply of services in an MCO’snetwork before the MCO is aware of it, we may per-suade the company to remedy the problem by contract-ing for our services. We can document complaints frompatients and primary care physicians when care is de-layed or unobtainable. These complaints are a more ac-curate index of an MCO’s network needs that its owndatabase, which often lists “phantom providers” whoare not actually available.

■ ENHANCING INCENTIVE

In addition to tailoring our services to meet an MCO’sneeds, we may enhance its incentive to contract with usby influencing other market conditions that determinesupply and demand.

Contracting as a Group

One tactic is to affiliate with other clinicians and thencontract as a group. Federal antitrust laws prevent usfrom bargaining collectively unless we are fiscal part-ners or employees, but assuming that a partnership does

61

not violate these laws, it can enhance our influence. Ifan MCO needs the services of one clinician in a smallpartnership, the MCO must contract with all partners toobtain those services. If a large partnership includesmost clinicians in a region, an MCO may be obliged tocontract with all partners to obtain sufficient servicesfor its subscribers. In addition, clinicians can offer bet-ter services as a group than they can individually, bycoordinating services and improving crisis responsive-ness (Poynter 1994; Schreter 1995).

Seeking Allies

We may also enhance demand for our services by mar-keting them to those who influence an MCO’s contract-ing decisions. MCOs are sensitive to the opinion ofregional politicians and to input from business executiveswho purchase insurance for large companies. MCOs mayalso be responsive to primary care physicians who carefor a large number of their subscribers.

■ CONCLUSION

Unless we practice in an underserved area or provide arare, much-needed clinical service, we must marketour services. Whether resources are managed byMCOs, the government, or large clinical organizationssuch as an integrated delivery system, we must per-suade resource administrators that they need our ser-vices for their network or staff. The only alternative—

62

becoming insurers as well as clinicians by acceptingprepayment for our services—creates an unacceptableconflict of interest by providing us with a strong incen-tive to deny needed care (Mechanic and Aiken 1989;Schreter 1999).

We can usually obtain contracts with MCOs byknowing how to practice managed care, being persis-tent, understanding the needs of the market, and usingall legal means to influence it. We may yearn for thegood old days when marketing was unnecessary, butassuming that they will not return, we discover that wehave many resources and will probably acquire more astime goes on.

■ REFERENCES

American Managed Behavioral Healthcare Association:Performance Measures for Managed Behavioral Health-care Programs (PERMS 2.0). Washington, DC, AmericanManaged Behavioral Healthcare Association, 1996


Blumenthal D: Quality of health care, part 1: quality of care—what is it? N Engl J Med 335:891–894, 1996

Brook RH, McGlynn EA Cleary PD: Quality of health care,part 2: measuring quality of care. N Engl J Med 335:966–970, 1996


63

Mechanic D, Aiken LH: Capitation in mental health: poten-tials and cautions, in Paying for Services: Promises andPitfalls of Capitation (New Directions for Mental HealthServices, No 43). Edited by Mechanic D, Aiken LH. SanFrancisco, CA, Jossey-Bass, 1989, pp 1–16

National Committee for Quality Assurance: Standards andSurveyor Guidelines for the Accreditation of MBHOs.Effective July 1, 2001. Washington, DC, National Com-mittee for Quality Assurance, 2001

Pomerantz JM, Liptzin B, Carter A, et al: Development andmanagement of a “virtual” group practice: behavioral cli-nicians and organizations linked by a capitation contractwith an HMO. Psychiatric Annals 25:504–508, 1995

Poynter WL: The Preferred Provider’s Handbook: Buildinga Successful Private Therapy Practice in the Marketplace.New York, Brunner/Mazel, 1994

Sabin JE: Managed care: getting managed care organizationsto cover extended psychotherapy for patients with person-ality disorders. Psychiatr Serv 47:365–366, 1996

Sabin JE: What our students teach us about managing careethically. Psychiatr Serv 49:879–881, 1998

Sabin JE, Daniels N: Determining “medical necessity” inmental health practice. Hastings Cent Rep 24:5–13, 1994

Schreter RK: Earning a living: a blueprint for psychiatrists.Psychiatr Serv 46:1233–1235, 1995

Schreter RK: Essential skills for managed behavioral healthcare. Psychiatr Serv 48:653–658, 1997

Schreter RK: Reorganizing departments of psychiatry, hos-pitals, and medical centers for the 21st century. PsychiatrServ 49:1429–1433, 1998

Schreter RK: Physician service networks and the future forpsychiatrists. Psychiatr Serv 50:415–416, 1999


65

5

MANAGINGUTILIZATION REVIEW

When, as managed care practitioners, we become inter-ested in managing the clinical work of others, our goalis often to correct problems in the health care systemand realize a vision of good clinical care, fairness, re-sponsiveness, and efficiency. Not long after beginningsuch management, however, we encounter a number ofproblems. When we manage the work of other clini-cians, we can intrude only so far into the special clinicalresponsibilities of those who directly treat patients.Whatever our opinions about a patient’s treatment, ourinformation is incomplete because we have not methim or her. Whatever our responsibilities, we have notbeen chosen by the patient, nor have we accepted directresponsibility for the patient’s safety and well-being. Inaddition, if a clinician finds us overbearing or critical,we may receive less information and thus be more aptto make bad resource decisions that will compromisethe patient’s care. Far from acquiring more power overthe quality of care, we find we must proceed carefullyand acquire new skills if we are to have a positive influ-

This page intentionally left blank This page intentionally left blank

66

ence. We continue to feel that administrative man-agement is necessary to induce clinicians to conserveresources. We are grateful that good managed carepractitioners need little oversight (Pomerantz et al.1995). The challenge is to develop a collegial methodfor gathering information, making resource decisions,offering advice, and staying focused on the patient’swelfare.

■ ADVOCATING FOR GOOD MANAGED CARE

When we review the clinical work of others, we mustmaintain a consistent, positive role vis-à-vis the patient,regardless of our relationship with the patient’s clini-cian or the managed care organization (MCO). Weshould see ourselves as a concerned friend of the pa-tient, someone who is committed to and responsible forpaying for good health care but who cannot afford towaste money. As part of this role, we advocate forgood, efficient care and make resource decisions basedon the information we receive. Here are two examples:

Three days after a patient overdosed on medicationand was admitted to an inpatient psychiatric ser-vice, he denied suicidal ideation and asked to be re-leased. His clinician could find no evidence of pastsuicide attempts but nevertheless believed that thepatient’s statements could not be trusted and thathis risk of harm remained high. A care manager

67

reviewing the case for an MCO felt compelled toaccept the clinician’s judgment and authorize pay-ment for additional days.

When an inpatient’s psychotic symptoms did notimprove over a 3-day period, an MCO care managerwondered why the dose of antipsychotic medica-tion, which was relatively low, was not increased.As long as the treatment fit within standard guide-lines, however, the care manager did no more thanask for an explanation of the current dose and won-der what would be done if the patient’s conditiondid not change. If the dose were truly substandard,the care manager would ask a physician advisorto review the case to determine whether treatmentcould be expected to have restorative potential. Ifthere was no such potential, the treatment could notbe considered medically necessary.

Maintaining a Clinical or Fiscal Barrier

Our role as a patient advocate should not be influencedby an MCO’s fiscal condition or management style. Wemust apply benefit limits, review clinical information,and authorize payment for medically necessary treat-ment in a way that is fair, consistent, and respectful ofthe patient’s needs and the clinician’s special respon-sibilities. If our MCO colleagues ask us to review casesmore aggressively, we must ignore the request and con-tinue to apply clinical principles consistently. If ourcolleagues dislike or mistrust a certain clinician, weshould not let these considerations bias our review or

68

distract us from the clinical facts and our primary re-sponsibility, which is to the patient.

Reviewing Medical Necessity

When we ask clinicians about the efficiency of theircare, we hope that our questions will benefit the patientas well as conserve resources (Green 1989). We mightask: “Could you help me understand why this treatmentis necessary?” “What will the treatment accomplishthat a less costly treatment will not?” “What is the onething that needs to change before this patient can bestepped down to less intensive treatment?” “What harmis there in discharging the patient today?” “Why wouldthis treatment help now if it was not helpful last year?”“Why should you continue this treatment if it does notseem to be working?” “How much support can the fam-ily provide?” The best questions are those that are sim-ple, represent a patient’s best interests, would be askedby a concerned relative, and respect the right of clini-cians to come to their own decisions.

Promoting Standards of Practice

We should ask clinicians about their reasons for choos-ing treatments that do not seem to comply with standardsof practice. “If this patient has symptoms of depression,shouldn’t he have an immediate psychiatric evalua-tion?” “Wouldn’t an atypical neuroleptic carry less riskof side effects than a typical one?” “Would Topamax

69

[topiramate] counteract the tendency of his other med-ications to cause weight gain?” “This patient has notresponded to several neuroleptics. Has he ever receiveda trial of clozapine?” “If you help the patient recovermemories of abuse, will it not cause her to becomemore depressed?” Good questions help clinicians thinkabout their decisions but do not threaten them orimpose our decisions on them.

Educating Patients

If patients wish to speak to care managers directly, weshould be able to explain our resource decisions to themwhile assuring them of our commitment to good care.We might say:

From what your clinician tells me, you no longerneed hospital care and will recover as quickly athome. Your insurance will cover the treatment thatyou need. If you relapse, your clinician will have notrouble obtaining authorization for readmission.

Pinpointing Patient Influence Over Resource Decisions

On occasion, our input about resource managementmay help a clinician pinpoint a patient’s influence overresource decisions. A clinician might be informed:

Your patient needs to know that I cannot authorizeresidential treatment after he completes alcohol

70

detoxification, because he continues to reject AA[Alcoholics Anonymous] and refuses to live in a so-ber setting. If he can persuade you and me that treat-ment has restorative potential, I would be happy toauthorize it.

Encouraging Realistic Decisions

When treatment options are running out, input aboutresource management may remind clinicians that goodtreatments are not always effective and that it is time tofocus on managing problems as they are. Here is anexample:

Treatment in your program and previous programshas been excellent, and that is why I doubt thatanother 2 weeks would be helpful. This is a goodpatient with a bad illness who has received goodclinical care from good clinicians. I don’t thinkmore time in this program will be helpful.

■ FINDING SUPPORT FOR QUALITY IMPROVEMENT

If our job includes responsibility for quality improvementand utilization review, we may have opportunities to con-ceive and propose improvements in the system of care. Itis then that we discover that we must gather supportwithin the MCO to fund needed changes, because mostchanges are costly and do not necessarily save money.Fiscal managers become anxious about changes that may

71

increase service utilization and thus expenses. For thisreason, we need to show that our proposals will benefit anMCO as a business as well as improve patient care.

For persuasion, we rely on the tools described inChapter 4 that help clinicians obtain contracts withMCOs. We show that our proposals will improve acompany’s performance on measures that help it secureaccreditation, win bonuses, or score well in nationalcomparative rating systems. With creativity, we devisemeaningful improvements that affect performancemeasures. Consider the following approach:

To obtain funding from an MCO for a depressionscreening program, a medical director showed thatthe data gathered would improve the company’sstanding in a national measure of performance.

■ CLOSING THE SEAMS BETWEEN SYSTEMS

Whenever possible, we should bridge gaps between theacute care coverage of private insurance and the long-term custodial benefits of the public sector. Without col-laboration at a high administrative level, care systemstend to exclude problems from coverage without con-sideration of eligibility for other resources. As a result,many children with behavioral problems and adultswith persistent mental illness or dual diagnoses exhausttheir acute care benefits before they are eligible for thelonger-term residential treatments that they need. As

72

senior clinical administrators, we may be able to col-laborate with our counterparts in other systems to nar-row these coverage gaps.

■ CONCLUSION

We who manage managed care are responsible for mak-ing the system work for patients. We should manage theefficiency and quality of care aggressively while pro-tecting their right to good managed care. When we de-cide whether to authorize payment for treatment, weperform an evaluation of medical necessity that isprimarily professional and clinical, although we do notnecessarily interact with patients. In performing thisevaluation, we are accountable to professional stan-dards only and should not be influenced by fiscal pres-sures or personal prejudice. In this respect, we musthave the impartiality of judges.

As clinicians become more expert at practicing man-aged care, we who manage it find fewer instances ofwaste and have more opportunities to solve problemswith our clinical colleagues. It is satisfying to make asuggestion that results in a better, more efficient treat-ment plan. If our input also encourages clinicians tospeak more realistically with their patients about long-term prognoses and service needs, so much the better.In the long run, we hope that our experience as man-aged care practitioners and administrators will guide usto imagine, recommend, and implement a better systemof care.

73

■ REFERENCES


Pomerantz JM, Liptzin B, Carter A, et al: Development andmanagement of a “virtual” group practice: behavioral cli-nicians and organizations linked by a capitation contractwith an HMO. Psychiatric Annals 25:504–508, 1995


75

INDEX

Accreditation standards, 60Active treatment, 40–41Acute care

access to, 42–43comanagement, 41–42MCO monitoring of, 33resource conservation, 33timely review of, 43–46treatment change during,

40Acute incarceration, 34Advocate, care manager as,

66–70Alliances, with MCO

influences, 61American Managed

Behavioral Healthcare Association, 58

Appeals process, 12, 47–48Appointments, scheduling,

55–56Availability of care, 1–3

Behavioral problems, non-DSM-IV-TR, 5

Bias, avoiding, 67–68Borderline personality

disorder, 54

Care managementadvocacy role in, 66–67bias elimination in, 67–68medical necessity review,

68Case management, 11–12Comanagement

of acute care, 41–42of coverage issues, 22importance of, 9–11of treatment frequency,

24–25Concurrent review, of acute

care, 43–46Conditions, disease

focus on covered, 52long-term treatment of, 54

76

Coverage. See alsoEligibility criteria

alternatives to, 34–35denial of. See Denialsscreening for, 34

Credentials, presenting, 51–57

Custodial carenoncoverage of, 34resources for, 53

Decision makingcooperative, 9–11patient influence on,

69–70realistic, 70

Denialshandling, 47–48understanding, 28–29

Depression, 53Diagnostic and Statistical

Manual. SeeDSM-IV-TR

Diagnostic criteria, DSM-IV-TR, 4–5, 21

Disease conditionsfocus on covered, 52long-term treatment of, 54

Documentation, for MCOs, 26–27

DSM-IV-TR, diagnostic criteria, 4–5, 21

Education, of patients, 69Effectiveness, of treatment,

7–8Eligibility criteria, 3–6

for nonacute care, 20–22Empowerment, through

managed care, 55Entitlement, 44Ethical goals, of managed

care, 1–3Evaluations, for level of

care, 35–38Evidence

of covered mental illness, 21–22

of treatment necessity, 29

Experience, demonstrating clinical, 51–57

Family support. SeeNonprofessional support

Follow-up care, 56Frequency, of treatment,

23–24

Group contracts, 60–61

77

Harm, to patientassessing risk of, 7high risk of

diminished, 39treatment choice for,

36–37Hospital affiliation, lack of,

57

Impairments, monitoring, 24Improvement

as eligibility criteria, 5–6monitoring, 8

Indemnity insurance, 2Insurance coverage. See

CoverageInsurance, private

alternatives to, 6public sector bridge with,

71–72Intensive outpatient

programs (IOPs), 35Intensive treatment

denial of, 28–29little justification for, 30MCO prejudice against,

57need for, 36–37

Intermediate care programs, development of, xiv

Interviews, with MCO administrators, 51–57

IOPs. See Intensive out-patient programs (IOPs)

Legal assistance, referral for, 12–13

Levels of carechanging to lower, 39–40choosing, 35–38communicating with

MCO about, 44–45highest, 36–37subacute, 37–38

Managed careadvocating for, 66–70ethical goal of, 1–3managing, 65–72and nonacute care, 19

access to, 25–26resource conservation in,

xiiworking definition of, xiv

Managed care organizations (MCOs)

acute care access, 42–43acute care monitoring, 33clinical responsibilities,

xv–xvi

78

Managed care organizations (MCOs) (continued)

negative prejudices of, 56–57

payment commitments, 43–46

unadvertised needs of, 57–60

Marketability, clinical, xvi–xvii

demonstrating, 51–57improving, 13incentives to heighten,

60–61for unadvertised needs,

57–60Massachusetts Mental

Health Center, xiiiMCOs. See Managed care

organizations (MCOs)Medical necessity. See also

Levels of caredetermining, 6–9patient discussions about,

42reviews of

care manager, 68peer, 55

Medical recordsreviewing, 21, 23

patient’s refusal to consent to, 37

Mental illnesscoverage for, 20documenting, 21–22

National Committee for Quality Assurance, 58

Network membership, denial of, 56–57

Nonacute careaccess to, 25–26advantages of managed

care for, 19amount of needed, 22–25coverage determination,

20–22frequency of, 23–24providing, 54–55

Nonprofessional support, 8–9

availability of, 38communicating with

MCO about, 46

Out-of-network services, 43Outcome measures,

monitoring, 8Outpatient therapy,

nonacute. SeeNonacute care

79

Oversupply, of behavioral health services, 51

Parity, of medical and mental illness, 4

Part-time practice, 57Partial hospitalization

programs (PHPs)effectiveness of, 38level of care in, 36

Partnerships, physician 60–61

Patientseducation for, 69treatment decisions of.

See ComanagementPeer review, of medical

necessity, 55Performance improvement

as marketing tool, 58–59support for, 70–71

Posttraumatic stress disorder, 54

Psychoanalysis, 57Public sector, insurance

bridge with, 71–72

Quality improvementas marketing tool, 58–59support for, 70–71

Relapsepreventing, 23–24risk of

assessing, 7–8communicating with

MCO about, 46Residential treatment

level of care in, 36noncoverage of, 34

Resource conservationduring acute care, 33advantages of, xiipatient influence on,

69–70traditional management

of, 2Resources, alternative,

xiii–xiv, 6, 11, 34–35. See also Special services

Restorative potentialcommunicating with

MCO about, 45of treatment, 23

Review, concurrent, 43–46

Safety, patient, 45–46. Seealso Harm, to patient

Screening process, for eligibility, 34

80

Severe behavioral dysfunction

coverage for, 20documenting, 21–22

“Shotgun” therapy, 40–41, 48

Special servicesobtaining, 11–12undersupply of, 58

Standards of practice, promoting, 68–69

Subacute care, need for, 37–38

Suicide attempts, 54

Teaching-hospital practice, 57

Treatment costsnonmonetary, 2responsibility for

managing, 1–3

Treatment planscommunicating with

MCO about, 44–46managed care principles

and, 12medically necessary, 6–9

Treatment priorities, hierarchy of, xiv

Treatment reports, provided to MCOs, 26–27

Underserviced regions, 58Undersupply

identifying, 60of specialty services, 58

Unmanaged benefits, 27–28Utilization review, 65–73.

See also Performance improvement

Documents

Concise Guide to Managing Behavioral Health Care Within a Managed Care Environment (Concise Guides)