Comparison of public/private health care insurance parameters for independent psychological practice.

Managed care cost-cutting strategies are more prevalent in the private (employer provided) than public (Medicare/Medicaid) health care sectors. The main organizational managed care strategy pertaining to the independent practice of psychology has been the separation of the administration of mental from medical health care though behavioral health carve-outs. These organizations typically offer lower reimbursement rates and have greater preauthorization requirements than non-managed care public plans for the same psychological service. Dispute resolution in the private sector involves lawsuits and state consumer protection programs while public plans utilize internal review and are subject to investigations of provider billing fraud and abuse. Behavioral health carve-outs have reduced mental health care utilization rates with unknown effects upon outcome. There is some evidence that psychologists have chosen to limit practice within the private sector, but national data on the overall effect is lacking. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pay for performance in primary and specialty behavioral health care: Two "concept" proposals.

Incipient pay-for-performance (P4P) plans offer to improve the quality of general medical care, but they have not yet begun to influence clinical outcomes in the behavioral health care arena. Following a brief review of the quality chasm in behavioral health care and some initial applications of P4P programs, this article presents 2 bird's-eye view proposals with which the primary and behavioral specialty care sectors of the American health care system can begin to design and implement P4P incentives. Discussion of the value of behavioral health care, the Provider Quality Index, P4P implementation issues, implications for practicing psychologists, and some cautionary notes conclude the article. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managed competition in practice: 'value purchasing' by fourteen employers

Many large U.S. companies have transformed their procurement of health benefits in the 1990s by combining the principles of managed competition with other business tactics to create a business-savvy hybrid of the private sector's own design, often referred to as "value purchasing." Until recently, few policymakers or health care observers believed that large firms would be a force in health system reform. Yet to implement value purchasing, the large companies in this study created new organizational forms, provided employees with financial incentives to select low-cost health plans, and used business tactics such as competitive bidding to negotiate more favorable rates and to improve quality among health plans. The financial results were impressive for the companies studied. In addition, the companies' demands on the health care delivery system are multiplying as the interface between business firms and health care organizations changes. These demands will only increase as the practices we found become more widespread.     

How expensive is unlimited mental health care coverage under managed care?

OBJECTIVES: To study costs, access, and intensity of mental health care under managed care carve-out plans with generous coverage; compare with assumptions used in policy debates; and simulate the consequences of removing coverage limits for mental health care as required by the Mental Health Parity Act. DESIGN: Claims data from 1995 and 1996 for 24 managed care carve-out plans; all plans offered unlimited mental health coverage with minimal co-payments. OUTCOME MEASURES: Probability of care, intensity of care, and total costs broken down by service type and type of enrollee. RESULTS: Assumptions used in last year's policy debate overstate actual managed care costs by a factor of 4 to 8. In the plans studied, costs are lower owing to reduced hospitalization rates, a relative shift to outpatient care, and reduced payments per service. However, access to mental health specialty care increased (7.0% of enrollees) compared with the preceding fee-for-service plans (6.5%) or free care in the RAND Health Insurance Experiment (5.0%). Removing an annual limit of $25000 for mental health care, which is the average among plans currently imposing limits, will increase insurance payments only by about $1 per enrollee per year. Children are the main beneficiaries of expanded benefits. CONCLUSIONS: Concerns about costs have stifled many health system reform proposals. However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates. For mental health care, the cost consequences of improved coverage under managed care, which by now accounts for most private insurance, are relatively minor.     

The role of psychology in health care delivery.

There is a wealth of professional opportunities for practicing psychologists, particularly given the recent recognition of psychology as a health care profession. A number of dimensions are discussed that can be used as a heuristic to outline the participation of psychologists in the general health care arena. Dimensions include the breadth of disease categories in which psychology has been involved, the involvement of psychologists at different stages of the progression of illnesses, and the diverse roles that psychologists may play in health care. Examples are provided to exemplify the contributions psychologists have made to health care. Recommendations are made to strengthen psychology's role in the health care system. Recent challenges are also reviewed regarding the association of health care and the delivery of services that demand the participation of psychologists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Simulation As a Tool to Assess the Vulnerability of the Operation of a Health Care Facility

Health care systems are classified as critical infrastructure systems when responding to disaster events. Physical damage to health care facilities or disruption of their operations or supply chains could prevent an effective response and aggravate the outcome of an emergency situation. Even if a hospital or public health facility were not directly affected by the disaster event, these facilities are required to operate efficiently during an emergency in order to manage a surge of capacity. When infrastructure systems are damaged as a result of man-made or natural disaster events, insufficient supply of resources through these systems affects their performance. In this paper, a system dynamics simulation model will be used as a tool to represent the operation of a health care facility, including the interaction between the different service areas (emergency room, intensive care unit, wards, operating room), the flow of patients inside the facility, and the condition of the infrastructure systems that supply resources (i.e., water, power, transportation of medical supplies) to maintain the operation of the facility. The results of this study may assist hospital administrators in their disaster preparedness plans, providing information regarding the level of occupancy and patients waiting to enter the service areas.     

Strategic choices for cost containment under a reformed U.S. health care system

The Clinton administration health reform proposal would impose global spending limits to bring the rate of increase in health care spending into line with the Consumer Price Index by 1999. This paper examines cost containment strategies available to states and health plans under externally imposed revenue limits. Drawing on the experience of state and local regulatory agencies, private sector managed care plans, and models in other countries, we contrast premium caps and provider rate setting as mechanisms to reduce growth in health care spending, and briefly consider the system-level regulatory structures necessary to oversee and control aggregate health care spending.     

Cost offset: Past, present, and future.

The health of the U.S. health care system is precarious. Calls for reform in areas such as cost, quality, and equal access to health care are widespread and growing louder each day. Action is required on each of these issues, yet the lack of progress is cause for serious concern. A central problem is the reluctance to acknowledge the roles that the mind and behavior play in health and illness. One solution is the integration of psychological health care into the general health care system. A major vehicle for advancing the integration of health care is the "cost-offset" effect, a concept that involves paying systematic attention to psychological factors in order to reduce overuse of medical services and thereby decrease costs. Despite data demonstrating that the cost-offset hypothesis is quite robust, little has been done to implement integrated health care. This article reviews the literature on cost offset, discusses the policy implications, and considers its application to the public sector. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Experiences of African American adolescent fathers

This study examines 1993 Medicare expenditures for enrollees in 63 managed care plans that were reimbursed on a cost basis. We find that government spending for enrollees in cost-reimbursed plans in 1993 was substantially greater than it would have been had these enrollees instead received care in traditional fee-for-service Medicare or in a Medicare risk plan. The increase was due entirely to the much higher expenditures for Part B services under cost reimbursement. The findings suggest that Medicare cost reimbursement of health plans should be eliminated or significantly modified.     

Psychiatric care and health insurance reform

Concerns about cost, access, and quality of health care in the United States have led to a variety of legislative proposals that would reform our health care system and its financing. Health insurance benefits for mental illness, including substance abuse, are treated differently from medical/surgical benefits, with stricter limits on outpatient visits and hospital days. Medicare, Medicaid, and most private health insurance plans contain this historic disparity of coverage for mental illness compared to general medical illness. Psychiatric services are also distinguishable because of the large public sector reimbursement for mental illness treatment and support. Principles for a more equitable design of mental health benefits include a non-discriminatory approach; payment on the basis of service rather than diagnosis; application of cost containment for care of mental illness on the same basis as care of general medical illness; retention of the public sector as a backup system for high-cost, long-term care; encouragement of lower-cost alternatives to the hospital through the development of a continuum of care; and a recognition of the distinction between psychotherapy and medical management. All current approaches to universal health care fall short of these principles. A research agenda is needed now more than ever in order to articulate the case for complete coverage of mental illness and substance abuse.     

Reexamining the delivery system as part of Medicare reform

Medicare is more than a payment system. As the nation's largest public payer of health care, Medicare dictates the way health care is delivered to elderly and disabled persons. Health care and health outcomes cannot make substantial improvements until the delivery system is changed. Medicare reform must support a coordinated health care delivery system (in place of hospital-centered, fragmented care) and proactive chronic disease management (in place of episodic, reactive care). Consumers, government, community-based agencies, employers, health plans, and others need to develop a shared understanding of what outcomes we want to obtain, what delivery system reforms are required, and how financing can support those reforms.     

U.S. mental health policy: Proactive evolution in the midst of health care reform.

Argues that it is vital that psychological and behavioral health care perspectives be explicitly recognized during the coming reform of the US health care system. Mental health policy should not be treated as a mere extension of physical health policy; to do so extends all the flaws of the physical health system into the psychological care arena, resulting in a mismatch with the actual health care needs of the nation. Furthermore, organized psychology must remind policymakers that psychologists provide health services in areas of health care beyond mental health. The challenge to psychology is to ensure the continuation of adequate and timely access to appropriate psychological and behavioral health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Evolution of Behavioral Primary Care.

The financing, organization, and delivery of behavioral health care services has undergone dramatic change in the past 25 to 30 years. The authors trace the evolution of behavioral health care delivery in the United States over the past several decades and find (a) that the value of mental health "carve-outs" has diminished greatly and that they are being replaced by "carve-ins," (b) that primary care physicians (PCPs) are becoming a primary source of mental health care secondary to the introduction of new medications, and (c) that PCP treatment of mental health disorders is suboptimal. The authors conclude that the behavioral health care system is entering an era of flux as it experiments with ways of integrating behavioral and primary care. Opportunities for psychologists are explored. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A perspective on the nation's antitrust policies: Implications for psychologists.

In response to significant change in the health care market, federal antitrust agencies recently examined their past policies and future directions for antitrust law enforcement in the health care industry. This article reviews how the federal antitrust laws have been used to both aid and restrict the practice of psychology, psychologists' dealings with managed care, and the limits of antitrust law enforcement efforts. Finally, we argue that narrowly crafted antitrust reform would provide practicing psychologists and other health professionals with some degree of countervailing bargaining power in their negotiations with managed care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

History, Politics, and Transformational Change in Canadian Health Care: A Rejoinder.

Our rejoinder addresses two common themes raised in the responses by Arnett et al (see record 2004-17185-005), by Hunsley and Crabb (see record 2004-17185-006) and by Mikail and Tasca (see record 2004-17185-007) to our article (see record 2003-09748-001) concerning the potential role of psychological services in the future of public health care in Canada. The first concerns the current system's capacity to evolve beyond the medical-hospital illness model of the 1960s to incorporate psychological treatments aimed at illness prevention and health promotion. This would be more likely if psychologists were to participate directly in primary-care and home-based mental health-care reform. The second theme is the presumed negative role of "politics" rather than scientific evidence in decisions concerning public coverage or subsidy. We argue that democratic decision-making is the proper basis upon which decisions concerning public coverage are made, but it need not be in opposition to evidence-based decision-making. As recommended in the final report of the Commission on the Future of Health Care in Canada, the Health Council of Canada along with applied research institutes can make politicians and policy-makers more aware of the growing body of evidence supporting the efficacy of psychological treatments relative to the alternatives. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managing dental care versus managed dental care: looking south from north of the 49th parallel

In the United States, aggregate expenditures on the largely private health care system, as a proportion of Gross National Product, exceed those of all other countries. Under private enterprise, the health care system in the United States grew as predicted by the underlying equation that more service volume equates to more revenue for hospitals and providers. Managed care is the response of for-profit health care organizations to meet the demands of U.S. corporations to contain the escalating costs of hospital, medical and other health care benefits for their employees. Managed health care has several models, but preferred provider organizations (PPOs) have been the model that has increased most rapidly. In contrast, managers of Canadian public dental programs plan, organize, direct and control more of the structures, processes and outputs to achieve desired outcomes for special groups. In Canada, the approaches to quality assurance, restraint of trade and the power of the professional lobby are different from the approaches in the United States. Nonetheless, the context of private dental care plans is very similar to the context that produced managed health care in the United States. Better management to meet demonstrated needs with evidence-based care can result in sustainable, adequately financed plans and avoid the deep-discount form of managed dental care.     

The action of ionizing radiation on the central nervous system (based on clinical and polymodal evoked potential data)]

A managed care plan's capitation payments should include an adjustment for its members' health status. Demographic and diagnostic information can be used to make the adjustment, which would help to minimize a health plan's potential financial liabilities. Without the adjustment, health plans have an incentive not to enroll persons with the heaviest care needs.     

Brief intervention, treatment, and recovery support services for Americans who have substance use disorders: An overview of policy in the Obama administration.

The Obama Administration plans to reinvigorate the U.S. system of care for substance use disorders through new health insurance parity regulations, the historic health care reform law (formally known as “The Affordable Care Act of 2010”), and the President's National Drug Control Strategy. Parity regulations and health care reform will significantly expand the availability of health insurance, and the proportion of health insurance plans that provide adequate benefits for substance use disorder care. The President's National Drug Control Strategy and Fiscal Year 2011 budget request make investments that will build on this foundation, including broad dissemination of screening, brief intervention and referral to treatment (SBIRT) techniques, integration of care for substance use disorders into Federally Qualified Health Centers and the Indian Health Service, augmentation of reentry programs and drug courts, creation of a pay for performance treatment quality initiative, and expansion of the Access to Recovery voucher program. Collectively, these policies will improve the quantity and quality of substance use disorder care and thereby promote public health and public safety. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Establishing an integrated care practice in a community health center.

In a progressively complex and fragmented health care system and in response to the need to provide whole-person, quality care to greater numbers of patients than ever before, primary care practices throughout the United States have turned their attention and efforts to integrating behavioral health into their standard service-delivery models. With few resources and little guidance, systems struggle to gather the support required to establish effective integrated programs. Based on first-hand experience, we describe a working integrated primary care model, currently utilized in a large community health center system in Colorado, that encompasses universal screening, consultation, psychotherapy, and psychological testing. With appreciation for the way an organization's unique circumstances inform the best approach for that particular organization, we highlight the clinical-level and system-level variables that we consider necessary for successful practice development and address how our behavioral health program operates despite funding limitations. We conclude that organizations that aim for integrated primary care must mobilize leadership to implement systemic changes while making difficult decisions about program development, financing, staffing, and interagency relationships. (PsycINFO Database Record (c) 2011 APA, all rights reserved)