Popple5 c9[1]

Copyright ©2011 Pearson Education Inc. All rights reserved.

CHAPTER 9 Mental Health:

Managed CareThe Policy-Based Profession

An Introduction to Social Welfare Policy Analysis

for Social WorkersFifth Edition

Philip R. Popple & Leslie LeighningerSlides by Heather Kanenberg, University of Houston, Clear Lake

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Managed Care

• Primary method of providing health care benefits today

• In 2008 over 65% of the Medicaid beneficiaries are enrolled in some form of managed care

• Managed Care Organizations have in recent years become the primary providers and administrators of mental health services in the U.S.


Managed Care: The Problem

• Which Problem?– The increasing cost of mental health care– The need to improve the quality of care for those

with mental illnesses– The need for corporations in the managed care

industry to increase their networks and to reach new areas of society

• How do we determine which is the driving force?


Mental Health Care

• Costs: – Ten percent of the health care expenditures are on Mental

Health Care– Untreated mental illness is estimated to cost $1923 billion

in lost earnings in the U.S.• Incidence & Treatment: – NIMH estimates that 26.2% of Americans 18 and older

suffer from a diagnosable mental illness– Difficulty determining the level of need and numbers in

need translates to difficulty projecting funding


Managed Mental Health Care

• Understanding Managed Care, its own vocabulary and vernacular

• Fundamentally a method of coordinating services and paying for health care service delivery–Manages: access to services, types & amount of

services, and choice with a goal of containing costs



• Understanding the system of care and delivery of services– Qualified MH professionals– DSM– Reimbursement– Authorization for Services (number of allowable

and reimbursed visits)– Emphasis on short-term care deliver



• Managed Care from a providers perspective• Managed Care from the perspective of an

agency staff person• Managed Care in the public sector• Careful consideration of restrictions, access,

response to need/demand, quality of care, and support of clients is required


Managed Care: History

• Date back 60 years• New Deal legislation – Medical Cooperatives– Kaiser Permanente, 1942

• Health Maintenance Organizations supported under Nixon

• HMO Act of 1973• By 1991 more than 38 Million people enrolled

in HMO’s


Managed Mental Health Care: History

• Traditionally the responsibility of the public sector; public mental health authorities

• Insurance coverage for mental illness began in the 1950’s

• Benefits are driven duration of treatment rather than the services needed

• HMO’s began to cover mental health and substance abuse services in the 1970’s

• Mid 1980’s brought the development of separate and sub-contracted Mental Health Managed Care Organizations


Managed Health Care: Economic Analysis

• Cost containment as a goal; moderate success initially• Economic and social changes coupled with

advancements in medicine and pharmaceuticals have resulted in rising health care costs

• Increasing premiums create difficulties for beneficiaries

• Reduction in market competition among MCO’s had minimized the need to offer ‘competitive’ (lower) costs to beneficiaries


Managed Health Care: Social Analysis

• Mental Illness understood as a result of immorality vs. the view that it is a disease or “problems in living”

• Market forces can solve both economic and social problems

• Collective & societal response to health problems vs. market mechanisms handling health needs of the public


Managed Health Care: Political Analysis

• Multi-billion dollar industry with stakeholders at every level of our society and community– Clients, employers, state health officials, providers,

MCO’s, legislators, advocacy groups, the broader public, etc.

– Competing interests, goals, ideals, result in fragmented voices, advocacy and attempts at reform

• Clients & their families struggle; many consumers are not organized the way beneficiaries in other programs are traditionally organized


Managed Health Care: Social Work

• Our Roles:– Provider– Advocate– Planner

• Responsibility to work for reform• Opportunity to encourage ethical practice that

promotes quality of life and ‘least restrictive’ options


Managed Mental Health Care: Issues

• Autism & Vaccination• Online provision of mental health services• Mental health care for Veterans• Mass tragedies – violence in schools,

campuses, etc.


Managed Health Care: Proposals for Reform

• Mental Health Parity Legislation– Federal Level– State Level

Business

Popple5 c9[1]