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 However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates.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.     

Adolescent health care: A public policy perspective.

Focuses on the importance of psychosocial and behavioral components of health care in the area of adolescent health care. The authors contend that it will ultimately be as a direct result of psychology's tangible (and visual) successes in areas such as adolescent health that will lead to psychological services becoming fully accepted within the overall health care system. The underlying policy notion is that if psychology addresses society's perceived needs, society (i.e., the nation's public policy/political leadership) will strive to meet the mental health profession's needs. The majority of problems adolescents face, regardless of apparent physical symptomatology, are essentially behavioral (psychosocial) in nature. The symptom distress model provides for a school-based integration of psychological knowledge with clinical and educational expertise. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Analyzing the evidence on European health care reforms

Health system reform, in Europe as elsewhere, has often been influenced as much by theory and conjecture as by fact and experience. In a study published in September 1997, the Regional Office for Europe of the World Health Organization (WHO) drew together the available evidence about the health care systems in the fifty-one countries of the European region. This paper focuses on western European countries. It reviews a variety of policy strategies and then explores implications from this European experience for the formulation of U.S. health care policy.     

The family's role in long-term care

Long-term care provided by family members is the central care of our current health care system. The purpose of this article is to review the family's role in long-term care. Issues such as cost containment and inequities in our current social policy are reviewed. Suggestions for future directions in social policy are presented.     

Managed care and reproductive health

Managed care poses special challenges to midwives providing reproductive health care. This is owing to the sensitive nature of issues surrounding reproductive health and aspects of managed care that may impede a woman's ability to obtain continuous, confidential, and comprehensive care from the provider of her choice. Variations across payers (ie, Medicare, Medicaid, and commercial insurers) regarding covered benefits and reimbursement of midwifery services also may create obstacles. Furthermore, some physicians and managed care organizations are embracing policies that threaten the ability of midwives to function as primary health care providers for women. Despite these hurdles, midwives have the potential to remain competitive in the new marketplace. This article underscores the importance of being knowledgeable about legislation and policy issues surrounding the financing of midwifery services, quality performance measurement for HMOs as they pertain to reproductive health, and discussions regarding which clinicians should be defined as primary care providers.     

Collaboration in capitated care: Challenges for psychology.

This article highlights the mutual dependence of disciplines in capitated care systems, with a focus on a sample program at Kaiser Permanente. Challenges for psychology are discussed as they relate to intradiscipline issues, relationships with other psychosocial care disciplines, and broad health care systems issues. The author suggests that psychology's future in capitated care will rest on skills in research, program development, and specialty practice areas (e.g., clinical health psychology, clinical neuropsychology) and encourages advocacy for the elimination of mind–body dualism in health care policy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

Academic faculty practices: issues for viability in competitive managed care markets

This study compares the perspectives of eighteen managed care executives and twenty-four faculty practice executives on critical policy issues related to the managed care marketplace. Market sites studied in 1994 included four major metropolitan areas: Minneapolis-St. Paul, Los Angeles, Philadelphia, and Atlanta. These markets were selected as being representative of communities with descending degrees of managed care involvement, but with significant market activity. Study participants from both managed care systems and faculty practices examined five policy issues: (1) the importance of including academic medical centers in current and future health care plans for marketing purposes; (2) the provision of clinical services that are unique to the academic medical center, that is, unavailable elsewhere in the community; (3) the degree of financial supplement that employers might pay for including an academic medical center; (4) future restructuring of organizations to sustain the educational mission of academic faculty within a viable delivery system; (5) satisfaction of managed care providers with graduates of academic medical centers, as measured by the clinical skills of graduate physicians. The study findings showed little support among managed care plans for paying supplements to include faculty practices in a health care network. Most study participants from managed care systems and academic faculty practices identified limited competencies that are unique to academic centers. Moreover, managed care organizations were only willing to undertake limited restructuring at best to include faculty practices within their networks. General concern about the preparation of resident physicians (especially those in primary care disciplines) for practice within contemporary managed care organizations existed among managed care informants. The results of the study indicate that as traditional funding sources for medical education are reduced, schools require greater integration with managed care plans to enable academic medical centers and their faculties to continue promoting clinical enterprise.     

Psychology and public policy in the "health care revolution."

In this article we give a brief overview of the rapid changes taking place in health care delivery in this country, focusing particularly on cost-containment efforts, organizational restructuring of the medical-industrial complex, and this decade's procompetitive market. Psychologists need to be aware of current policy trends and potential future changes in health and to consider alternative roles in emerging health care systems. Further, mental health policy is heavily influenced by the form and context of health policy. We argue that a top-down analysis of resource allocation is necessary for responsible public policy in health and mental health care. We discuss opportunities and challenges for psychology within this framework in service, research, and education. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Private-sector care for chronically mentally ill individuals: The more things change, the more they stay the same.

Two profit-making industries, nursing homes and board-and-care homes, care for about one million chronic mental patients. This care is primarily custodial and probably not very different from the care patients received in the public sector prior to deinstitutionalization. Moreover, certain characteristics of privately owned facilities encourage poor patient care so as to maximize profit. The problem could be ameliorated if chronic mental patients were strong and informed consumers or if the public sector strongly regulated proprietary care. However, neither of these two conditions now hold. Perhaps the apparent difficulties in significantly improving care for chronically mentally ill individuals despite seemingly major changes in policy reflect a fundamental problem in overall social policy—a reluctance to care for chronically indigent individuals of all kinds. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health care reform: The 1993–1994 evolution.

Health care costs in the US continue to increase, as does the number of individuals who lack health care coverage. The magnitude of these critical problems assures that reform of the health care system will continue to be debated over the next decade. Increasing health care costs are associated with increased complexity of services and a greater number of health care providers. As health costs increase and the number of individuals covered by private insurance decreases, states will face increasing pressure to develop effective methods of providing coverage for those without health insurance. Employer mandates will be viewed as one method of extending health coverage. Psychologists must be involved in policy issues so as to ensure the utilization of psychological knowledge and attention to psychological and behavioral health needs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Informal care; a critical observation

In this article the policy aimed at cutting down expenses for professional care and at optimizing the contribution of informal, unpaid care (e.g. family caregivers and volunteers) is questioned. After a brief outline of the non-professional care system for the elderly, some problematic aspects of informal care are discussed, especially the influence of such care in terms of (over)burden, the quality of care and the consequences for the relationship between caregiver and person being cared for. Voluntary services are also questioned, particularly the lack of control, the power of volunteers and their knowledge, attitude and skills. It is concluded that expectations towards nonprofessional caregivers should not be too great. The importance of a finely tuned coordination and clear division of tasks in the care network is underlined. Finally a number of recommendations is made to settle the observed bottlenecks.     

Health care research and policy studies

Health economic studies in rheumatology have never been of greater policy importance, but unfortunately there are only a small number of researchers examining issues in this area. This paper reviews studies relating to economics and rheumatology as well as some important methodologic issues relating to conducting such studies. The topics covered include cost-identification analysis, physician variation, specialty versus subspecialty care, utility assessment, decision analysis, quality of life, time preferences and discounting, and sensitivity analysis. More than ever, now is the time to provide policy makers with evidence that rheumatologists provide medical care that is not only the finest from a medical perspective but the most cost effective from society's perspective.     

Focus groups reveal perils and promises of managed care for nurse practitioners

Decades of practice and research suggest that nurse practitioners (NPs) provide cost-effective and high-quality care. Managed care's emphasis on prevention and cost savings led some policy makers to view NPs as a way to meet the need for primary care providers. However, access to and utilization of NPs has increasingly been controlled by managed care organizations (MCOs) through their selection of providers for primary care panels. This study employed qualitative methodology to examine NPs' experiences with MCOs. Three focus groups, comprising 27 NPs in New York and Connecticut, revealed NPs' mixed reactions to managed care and a range of sentiments regarding NPs' efforts to be listed as primary care providers. The results reflected NPs' concerns about their perceived "invisibility," as well as their sense of "invincibility" in the ways in which NPs are responding to the barriers posed by MCOs. They identified barriers to, as well as ways to facilitate, being listed by MCOs, and described the importance of NPs working individually and collectively in negotiating with MCOs.     

New Jersey psychologists' report on managed mental health care.

New Jersey psychologists reported rankings of concerns encountered in their work with 10 of the state's managed care companies, and the authors propose a treatment concern cluster. Findings revealed that managed care negatively affects income and practice patterns, including pressure to change quality of care and compromise ethics. Degree of involvement in managed care differentially affected psychologists' responses. Not all managed care companies appeared equally problematic. Implications for clinical practice and public policy are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The stability of preferences for life-sustaining care among persons with AIDS in the Boston Health Study

In 1982, the World Health Organization (WHO) identified inadequate relief from cancer pain as an international health problem. WHO recommended that governments develop and implement national policies and programs for cancer pain relief. This report evaluates national health policy and the systems of health care delivery in relation to cancer pain management in the new South Africa. This field study included multiple methods of data collection: analysis of documents, field trips with participant observation in sites of care delivery, focused interviews, and in-depth interviews of key informants. The purposive sample of key informants (n = 33) represented multiple stakeholders in a variety of settings. Strengths of the developing health policy include specific recommendations related to palliative care; the shift to universal primary care; policies to support drug availability; the inclusion of morphine and codeine as essential drug at the primary health care level; and the development of a national standard related to cancer pain management. Health services are characterized by two parallel systems of care (private and public) with numerous vestiges of the inequities of apartheid. The management of pain varies by provider and setting; major problems with access exist in the rural areas. Health services in South Africa have been plagued by inequity and inadequate resources. New health policies have set a path to ensure universal access to health care including palliative care for cancer. Their successful implementation is the next necessary step toward improving health services and alleviating the suffering of increasing numbers of individuals with cancer.     

Infant day care and infant-care leaves: A policy vacuum.

Current US policy supports neither high-quality infant daycare nor alternatives, such as paid leaves for infant care. Psychologists, on the basis of research showing the importance of quality care for infants, should support measures to protect daycare quality and to help families afford decent care. At the same time, there are compelling child and family health reasons for psychologists to support voluntary, part-paid, 6-mo leaves for infant care. For 4 wks preceding and 6 wks following childbirth, working mothers should be eligible for a fully paid maternity leave. The remainder of the leave would be made available on a part-paid basis to either parent in any combination they chose to facilitate the parent–infant relationship. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bundled Medicare payment for acute and postacute care

One legislative policy option for controlling postacute care costs is for Medicare to make a "bundled" payment to hospitals to cover episode costs: acute plus postacute care costs. But a bundled payment might not match the costs of treatment as well as payment now does under Medicare's prospective payment system (PPS). Simulating hospital margins with and without postacute care costs, this paper finds that risks to the typical hospital would not increase under postacute care bundling. A central characteristic of a bundled payment is that it would cover multiple providers. From this characteristic comes bundled payment's major strength: cost containment.     

Health care for the whole person: Research update.

Quality health care must be informed by the best available scientific knowledge. This article offers research evidence supporting "health care for the whole person." We present an integrative biopsychosocial framework that can serve as a useful foundation for translational research endeavors and the development, evaluation, and dissemination of evidence-based health and mental health interventions. Pain and depression are used as exemplars of the biopsychosocial model. Empirical support for mental health interventions in primary care settings is highlighted, with particular emphasis on the treatment of depression across the life span. Research, practice, and policy implications based on the extant evidence base for health care for the whole person are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Grass roots participation in health care reform

Concerned citizens have responded to the health care crisis by developing the health decisions movement. American Health Decisions, a national consortium of 21 state organizations, leads a grass roots discussion network of community meetings committed to education and consensus on the ethical, technologic, legal, and economic issues (the tough issues) of health policy. The movement (with its stages of development, structure, process, and accomplishments) is described, and potential roles for physician cooperation and participation in forging functional, community-based health policy are delineated.