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Calibrate Systems to Ensure Outpatient Access and Quality
Managed care may always have negative connotations. This is unfortunate since management is not inherently negative, especially for large systems of care. Poor outcomes can be found with unmanaged care as readily as with tightly managed care systems. Resources are not unlimited in any healthcare system. Allowing their unfettered distribution does not guarantee an equitable result.
It is time to rethink our systems for providing outpatient behavioral care. We especially need to focus on the beginning and end of episodes of therapy. Our delivery systems often shortchange people at each point. People often do not get care when needed most, allowing disorders to progress unchecked. The amount of care needed varies by individual, and so it is vulnerable to arbitrary system limitations.
Health plans design many administrative systems driving healthcare delivery in our country. Managed behavioral healthcare organizations (MBHOs) were once independent payers in our field. They have now merged into health plans. What lessons can be learned about outpatient care from the MBHO years? In the absence of proprietary MBHO data, my personal recollections of those years must suffice.
Many decisions can be influenced by a potential for financial gain, even expert and professional ones. Managed care payers can restrict care based on financial incentives. Clinicians can be incentivized to extend care. These abuses, underutilization and overutilization, are antithetical to quality healthcare.
Regulators and accreditors expect monitoring and corrective action for these distortions of care. MBHOs discovered a simple way to avoid them. As circumstances allowed, they referred members to group practices. Groups reliably had lower utilization than individual clinicians. Why? Given steady referrals and the pressure to see new clients, groups had little incentive to needlessly extend care.
Group practices were trusted business partners of MBHOs, but at the same time they were expected to cooperate with metric-driven oversight of utilization. Is this description of the MBHO experience one that will be replicated as health plans assume responsibility for behavioral healthcare?
One future development is probably the decline of private practice and the growth of salaried clinicians in large delivery systems. These systems could replicate the MBHO experience with groups, but too many unknowns cloud such predictions. There are two critical variables to consider:
- whether funding (based on risk-sharing or an annual budget for services) supports adequate treatment
- whether meaningful oversight for underutilization occurs
What if a provider entity is given financial risk with minimal oversight of their utilization patterns? Consider accountable care organizations (ACOs). Many are capitated for all costs, including behavioral healthcare, and some have been allowed to offer very narrow behavioral healthcare networks. This has resulted in both underutilization and in reduced access to care.
Nothing could be further from what our field needs. Is this the future as health plans take control of behavioral care along with every other healthcare specialty? Insurers are ready to pass financial risk for all care to health systems. Will they allow behavioral networks to be restricted and care episodes to be limited? Will they downplay underutilization risks to focus primarily on urgent and emergent care?
The solution is not to emulate MBHOs here. We have some useful 20th century lessons, but we need categorically different solutions. Our first goal should be to boost care access. Yet if we succeed, demand for services will soon exceed clinician supply. We cannot train enough new therapists if full-length sessions remain the norm. Less than ideal replacements for therapy could proliferate.
For example, digital and virtual services are growing, and there will be temptation to insert them to manage demand and cost. While they surely have a role to play, we are better served by having therapists move into primary care with brief interventions tailored for that setting. After all, behavioral care is primary care, and therapists themselves drive much of the clinical change in treatment.
We should also remember: MBHOs did not encourage outpatient care. In fact, many encouraged employee assistance program (EAP) visits (with zero copay) to minimize behavioral health utilization. We should reverse this and drive up access to parity-compliant behavioral benefits. Let us track each modality, from brief visits to virtual and digital services, with incentivized annual access targets. This has been normative for EAP contracts.
The basic plan should be to align incentives to get people into behavioral care and keep them in it for as long as needed. Part of this would be placing therapists in primary care for greater convenience and for early problem resolution. Let us hold our delivery system accountable for increasing access every year. Remove any incentives that restrict care or extend it beyond what is needed.
Let us not pretend health plans will naturally do a better job than MBHOs. Their emphasis on integrated care or value-based financing will not automatically produce better access or appropriate utilization. We need contracts with clear expectations, routine monitoring, and meaningful incentives. The best systems are designed to hold everyone accountable for doing the right thing.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
