A survey of what clinicians should know

Administration and Policy in Mental HealthVol. 25, No. 1, September 1997

A SURVEY OF WHAT CLINICIANSSHOULD KNOW

Sharon A. Shueman and Miles Shore

There is general agreement among the major stakeholders—providers,consumers, payors, and managed behavioral health companies—that man-aged care poses significant challenges for behavioral health professionals,particularly those whose primary work has been in independent practicerather than organized care settings. In traditional independent practice,clinicians were free to employ relatively unstructured, goal-free approachesto care with an emphasis on patient insight and self-knowledge. Formalwritten treatment plans were a rarity and there was little external pressureon clinicians to complete treatment within any specified period of time.Often, little attention was paid to the efficient use of financial and serviceresources, and decisions to begin and end treatment were the purview ofthe therapist and the patient. Patients were generally seen as financiallyresponsible for their treatment regardless of employment based benefits.Indeed, such an approach to practice was consistent with the ways in whichmost behavioral health professionals were trained.

In contrast, clinicians practicing in today's managed care environmentare typically required to develop written, goal-focused, time limited treat-ment plans emphasizing the return of the patient to an adequate level ofday-to-day functioning while making efficient use of resources (Austad &Berman, 1991). Decisions to begin and end treatment, at least the part tobe paid for through the benefit plan, are made by the therapist and pa-tient together with a third party—the managed care entity.

In order to work effectively within this context, clinicians must be bothwilling and able to change their practice patterns, to at least accommodate

The authors are indebted to Warwick G. Troy, Ph.D., M.P.H., for his assistance in the development ofthe survey used in this study.

71 © 1997 Human Sciences Press, Inc.

Administration and Policy in Mental Health

to the new requirements and acquire the necessary knowledge and skill inorder to do so. Given the contrast between what was and what is nowrequired of them, the field is faced with a training challenge of significantproportions. Many, probably most clinicians currently in practice are not yetgetting the continuing education they need; those in training are not learn-ing the basic knowledge and skills (nor acquiring the attitudes) that willenable them to work effectively with managed care (Austad & Hoyt, 1992).

Despite the recognition and magnitude of the problem, little has beendone. Neither the professional schools, professional associations, govern-ment, nor the managed behavioral health organizations (MBHOs) havetaken the leadership to develop a comprehensive plan and program of train-ing. There are many reasons for this, but among the most apparent is the lackof understanding on the part of the organizations traditionally responsible fortraining about what needs to be taught (Blackwell & Schmidt, 1992).

Academic faculty as well as mentors and supervisors in clinical trainingsettings are not equipped with these competencies by virtue of their owntraining, and the lack of a nexus between academia and the MBHOs hasprovided little opportunity for trainers to learn directly about what theirtrainees need to know. Further, some faculty, perhaps many, have stereotypicnegative attitudes about managed care and, consciously or otherwise, mayconvey these attitudes to their trainees. The same problems exist for thosewith responsibility for the continuing education of clinicians in practice.

It is also true, for reasons related, in part to accreditation and profes-sional licensing requirements, that curricula have not been modified toincorporate the subject matter relevant to effective work in the context ofmanaged care (Troy, 1994). The changes that have taken place in the or-ganization and financing of health services have compounded the prob-lem, resulting in service settings that do not support the structures andprocesses necessary for even the traditional approaches to training. Forexample, government funding of trainee positions has dwindled; certainstructural requirements of accreditation bodies (such as psychology's re-quirement to have multiple trainees in any one site) make it difficult if notimpossible for many service settings to continue financially to supporttrainees, and MBHOs like their managed medical care and insurance com-pany predecessors have not assumed any major responsibility for fundingtraining.

THE SURVEY

As a first step in a process aimed at identifying the training needs ofbehavioral health professionals to work within managed systems of care,the authors developed and conducted a survey of senior clinician/adminis-

72


trators in managed behavioral health organizations to elicit their views ofthe skill and knowledge deficits of the behavioral health professionals withwhom they work. In collaboration with a consultant they developed a sur-vey of professional skills and knowledge areas which, in their judgment,are critical in order for providers to work effectively within managed be-havioral health. These authors and consultant have experience in man-aged behavioral health, in public and private behavioral health systems,and in the graduate training of psychologists and psychiatrists.

Knowledge and Skill Areas

The results of this analysis are found in Table 1. This table encompassesa range of clinical and administrative competencies relevant to the successof behavioral health professionals working with managed care. A surveyinstrument incorporating these 20 items was developed in order to solicitjudgments from senior clinician/administrators in managed behavioralhealth organizations about the current skills and knowledge of the net-work providers with whom they work as well as their training needs. Theprimary questions (keyed to the 20 items) asked of these clinicians were:

1. Do you believe that this is a critical skill or knowledge area for behav-ioral health providers working in managed care?

2. Provide a general estimate of the percent of your network providerswho possess this skill or knowledge.

3. Does your company train providers directly in this skill or knowledgearea?

4. Do you believe some other organization or entity should providetraining in this area (whether or not your company offers such train-ing to providers)?

5. Do you believe this skill or knowledge area should be included as acriterion in the credentialing process of managed care companies?

Respondents were also asked whether their companies provide informa-tion to their network clinicians about training resources so that these pro-viders could independently seek out training in these areas.

The Sample

Surveys were sent to 38 MBHOs ranging in membership from fewerthan 70,000 to more than 14,000,000 (based on data gathered in 1995).These organizations provided risk- and non-risk-based managed care, em-ployee assistance, and utilization review/case management services in allareas of the U.S. Combined, they cover more than 115 million people. Themean number of those covered was 2.96 million; the median was 730,000.

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The two-page survey was sent by facsimile with a request that it be com-pleted and returned, also by facsimile. Two distributions were required toachieve the return rate reported here.

SURVEY RESULTS

Nineteen responses were received, for a return rate of 50%. In terms ofsize (covered people) the respondents were representative of the 38 com-panies in the sample. In addition, among them they provide the full rangeof managed care, utilization review/case management, and employee assis-tance services.

Responses to the survey are summarized in Tables 1-3. The left handcolumns list the specific skill and knowledge areas and the middle andright hand columns reflect the responses to the five questions.

Which Skill/Knowledge Areas are Critical?

The "Is a critical skill" column in Table 1 contains the number of re-spondents who judged each skill or knowledge area to be critical for be-havioral health professionals working in managed care. In general and notsurprisingly, those most often seen as critical—i.e., areas endorsed by asignificant majority (16 or more) of respondents—are, by and large, skillsand knowledge that have a direct impact on the capacity of a provider towork successfully within managed care. They relate to the developmentand documentation of treatment strategies (i.e., goal-focused treatment,developing treatment plans, documenting care; Items 1, 2, and 18, respec-tively) and making efficient and appropriate use of available resources(i.e., coordination of care, dealing with personality disorders, use of com-munity-based services, and understanding medical necessity; Items 6, 7, 8,and 20, respectively).

Four items received very low levels of endorsement (less than 50%).Dealing with disabled and other underserved populations (Item 15) mayhave been seen as less critical than other areas since most of the respon-dent companies serve principally employed populations—groups that typ-ically include few disabled or traditionally under served people. Some ofthe companies did not provide EAP services and those that did, either mayconsider EAP as a specialty (required only of designated providers) or mayin contrast, think of EAP as requiring no specialized skills above thoseneeded for providing general behavioral health services.

Explanations for the low ratings on Items 8 (couples/family systemstreatment) and 14 (differentiating substance abuse from mental healthproblems) are harder to understand. The former would seem to be criticalto behavioral health systems concerned about the efficient use of re-sources. With regard to Item 14, this may be further confirmation of the

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TABLE 1Judgments of 19 Clinical Managers: Importance of and % Providers

Possessing Skill/Knowledge

Skill or Knowledge Area

Problem-oriented, goal-focused treatmentDeveloping realistic treatment plansUse of group and other alternative treatmentsProviding couples/family systems treatmentAppropriate use of inpatient servicesCoordination of care (with primary care and

other behavioral health providers)Dealing realistically with personality disorders

in a managed care contextKnowledge and appropriate use of commu-

nity-based service alternativesPrinciples of quality managementImplications of time limits on careKnowledge and use of prevention strategiesPrinciples of psychopharmacologyConsulting the research on efficacyDifferentiating substance abuse from mental

health problemsNeeds of people with a disability and other

traditionally under served groupsUnderstanding EAP servicesUnderstanding Disability, Workers' Comp.

and other workplace issuesHow to document care (being responsive to

concerns of MCOs)Understanding the meaning and implications

of benefit plansUnderstanding the meaning and implications

of medical/psychological necessity

Is a CriticalSkill

1917158

1417

18

17

15131314128

7

810

17

12

16

% PossessingSkill

49%48%35%42%49%44%

31%

37%

25%43%34%42%28%38%

35%

35%29%

43%

36%

39%

already ample evidence that substance abuse problems frequently go unre-cognized and therefore untreated by behavioral health professionals, eventhose in managed behavioral health organizations.

Providers' Skills and Knowledge

The right-hand column in Table 1 displays the mean respondent esti-mates of the percentage of their provider networks possessing the particu-

75

lar skill or knowledge. Follow-up discussions with the respondents suggestthat this number reflects the proportion of the provider network they be-lieve to be sufficiently skilled or knowledgeable to deal effectively with theirrequirements.

On the average, the respondents judged fewer than half of their net-work providers to be sufficiently skilled or knowledgeable in the specifiedareas. Those items receiving the highest endorsement relate to activitiesthat may be thought of as constituting the heart of managed behavioralhealth care: problem-oriented, goal focused treatment (Item 1); develop-ing realistic treatment plans (Item 2); and appropriate use of inpatientservices (Item 5).

The lowest ratings had to do with knowledge about the research onefficacy (Item 13) and quality management (Item 8), two activities typicallyseen as more germane to systems of care than to individual providers. An-other area receiving a low rating of endorsement was understanding disabil-ity, workers' compensation, and other workplace issues (Item 17), thingsthat are generally considered a specialty within behavioral health and,therefore, the purview of only a subgroup of providers.

Training in Skills and Knowledge Areas

Table 2 summarizes the responses related to the types of training pro-vided directly by managed behavioral health organizations as well as theirperceptions of their network providers' training needs. These responsesshow that while the respondents see a significant need in many subjectsareas their organizations are doing relatively little in the way of directtraining for their own networks. In all but one area (Item 17, Understand-ing Disability, Workers' Comp., etc.) at least 12 of the 19 respondents(63%) agreed that training is needed. At the same time, no single area wasa focus of training for more than 10 of the respondent companies. Fur-thermore, there was little correspondence between those areas thought towarrant training and those in which direct training is actually being done.For example, 18 respondents agreed that providers should receive trainingin group and other alternative treatments (Item 3) while only threeclaimed to do such training.

The bulk of the training being done by the respondent organizationsincludes goal-focused treatment, treatment planning, documenting care,and understanding medical necessity. With the exception of these, how-ever, little training is being done even to enhance those skills consideredcritical by the respondents. In addition, relatively few companies reportedthat they provide information on training resources for subjects other thanthose affecting the providers' most direct responsibilities to the MBHO.These include the four mentioned immediately above as being most oftensubjects of the MBHOs' own training programs as well as the use of inpa-

76 Administration and Policy in Mental Health

Sharon A. Shueman and Miles Shore 77

TABLE 2Survey of 19 Clinical Managers: Perceptions of Training Needs


Problem-oriented, goal-focused treatmentDeveloping realistic treatment plansUse of group and other alternative treatmentsProviding couples/family systems treatmentAppropriate use of inpatient servicesCoordination of care (with primary care and

other behavioral health providers)Dealing realistically with personality disorders in

a managed care contextKnowledge and appropriate use of community-

based service alternativesPrinciples of quality managementImplications of time limits on careKnowledge and use of prevention strategiesPrinciples of psychopharmacologyConsulting the research on efficacyDifferentiating substance abuse from mental

health problemsNeeds of people with a disability and other tra-

ditionally under served groupsUnderstanding EAP servicesUnderstanding Disability, Workers' Comp. and

other workplace issuesHow to document care (being responsive to

concerns of MCOs)Understanding the meaning and implications

of benefit plansUnderstanding the meaning and implications

of medical/psychological necessity

We Train

10103379

3

5

443228

1

63

9

5

9

SomeoneShould Train

171718121516

17

17

161514151417

13

97

18

12

16

tient services (Item 5), coordination of care (Item 6), and implications oftime limits on care (Item 10).

By and large, these 20 skill and knowledge areas were not seen as partic-ularly relevant to credentialing, the process whereby MBHOs decide whichprofessionals are eligible to provide what types of services to their mem-bers (Table 3). On only four items was there agreement among at leasthalf of the respondents that particular competency should be included in


TABLE 3Survey of 19 Clinical Managers: Importance of Skill/Knowledge as

Criterion in Credentialing


Problem-oriented, goal-focused treatmentDeveloping realistic treatment plansUse of group and other alternative treatmentsProviding couples/family systems treatmentAppropriate use of inpatient servicesCoordination of care (with primary care and other behavioral

health providers)Dealing realistically with personality disorders in a managed

care contextKnowledge and appropriate use of community-based service

alternativesPrinciples of quality managementImplications of time limits on careKnowledge and use of prevention strategiesPrinciples of psychopharmacologyConsulting the research on efficacyDifferentiating substance abuse from mental health problemsNeeds of people with a disability and other traditionally un-

der served groupsUnderstanding EAP servicesUnderstanding Disability, Workers' Comp. and other work-

place issuesHow to document care (being responsive to concerns of

MCOs)Understanding the meaning and implications of benefit plansUnderstanding the meaning and implications of medical/psy-

chological necessity

ShouldCredential

12118489

6

8

710696

116

44

8

49

the criteria used to credential providers. These items are goal-focusedtreatment, development of treatment plans, implications of time limits oncare, and differentiating substance abuse from mental health problems.

DISCUSSION

Clearly the senior clinician/administrators in the survey see a need toenhance the skill and knowledge of their contracted clinicians; their orga-

78

nizations are doing relatively little in the way of training to help bring itabout; but they believe such training should be done.

It may be instructive to imagine a group of clinical managers in commu-nity mental health centers, for example, who hold similar views about thecompetence of their staff clinicians. Were their judgments similar to thosereported in this survey, they would likely develop a plan for staff training.With regard to behavioral health professionals providing services in man-aged care, however, there has been little in the way of an organized expres-sion of dissatisfaction with the prevailing level of expertise and no signifi-cant efforts to address it. What is the difference?

Within a site-based organized service system, clinician/administratorshave a clear responsibility to ensure that the employed staff does have therequired competencies. There is clear accountability in such settings and,in addition, training is almost always included within their mission.

For the network of independent practitioners who make up a large pro-portion of the managed behavioral health networks, and who typicallywork with multiple organizations, no single entity is clearly responsible fortraining. Since these organizations often compete with one another inareas where their networks overlap, training providers may be seen bythem as providing no real competitive advantage. Further, even a smallmanaged behavioral health organization has 5-6,000 clinicians in its net-work while the largest companies may have 30-40,000 or more. The costsof training would be huge. In fact, MBHOs are more likely to deal with thetraining issues by selecting out—using a variety of provider profiling strate-gies as a way to screen out those providers whom they determine to havesignificant deficiencies and refer only selectively to others.

LIMITATIONS

While the authors believe that the results of this survey are useful, thereare clear limitations to its validity. No attempt was made to use a rigoroussampling methodology. The 38 companies surveyed were taken from amailing list provided by a journal published primarily for those in the man-aged behavioral health field. Further, while a response rate of 50% may,under many circumstances, be considered a sufficiently large sample toallow generalizations, in this case, the small absolute number of respon-dents suggests caution.

The survey did not include a definition of terms so there could havebeen significant variation in how the individual respondents interpretedthe items. This would affect the reliability and, therefore, the validity ofthe responses. In addition, for some managed behavioral health clinician/administrators, provider competence may be judged on the basis of docu-mentation (e.g., treatment plans, progress summaries, etc.). Particularly so

Sharon A. Shueman and Miles Shore 79

in behavioral health, documentation may not be a valid proxy for compe-tence. In addition, some of the respondents to this survey deal on a dailybasis with the work products of their network providers, others are moreremoved and, therefore, would be less directly informed about quality andcompetence.

The survey did not require respondents to differentiate between pro-vider types. It may be that specific deficits are observed more often withina particular mental health discipline (e.g., social workers may be moreknowledgeable about the use of community-based alternative services, psy-chologists may be better at developing problem-oriented treatment plans).It also did not differentiate between clinicians who work in groups andthose in individual practice.

CONCLUSION

Some practicing behavioral health professionals, perhaps many, take theposition that because managed care did not exist when they were in train-ing, its new performance and competency requirements should not be ex-pected of them. We would argue to the contrary that the 20 items listed inTable 1 are skill and knowledge areas desirable in any service setting, in-cluding fee-for-service independent practice. They are necessary prerequi-sites to the provision of appropriate care and use of resources.

Despite the survey's methodological shortcomings (though the highlevel of consensus across respondents suggests acceptable reliability), theunavoidable conclusion is surely that the field at large and behavioralhealth in particular had a problem. The results point to a significant levelof dissatisfaction by the clinical leaders (people with broad experience inbehavioral health) of the organizations in the survey with the ability ofbehavioral health professionals to work with sufficient competence in man-aged care. The discrepancy between what training is being done and whatis needed appears very large and the failure on the part of the managedbehavioral health organizations as well as those institutions traditionallyresponsible for such training is disturbing. There seems no way forwardbut for the multiple stakeholders in behavioral health to begin to moveoutside their traditional roles, to recognize the magnitude of the problemand to seek effective ways to resolve it. As discussed elsewhere in this vol-ume, this requires a significant paradigm policy shift, the infrastructure forwhich does not currently exist.

REFERENCES

Austad, C.S., & Berman, W.H. (Eds.). (1991). Psychotherapy in managed health care: The optimal use of timeand resources. (1st ed.). Washington, DC: American Psychological Association Press.



Austad, C.S., & Hoyt, M.F. (1992). The managed care movement and the future of psychotherapy.Psychotherapy, 29, 109-118.

Blackwell, B., & Schmidt, G.L. (1992). The educational implications of managed mental health care.Hospital & Community Psychiatry, 33, 962-964.

Troy, W.G. (1994). Developing and improving professional competencies. In S.A. Shueman, W.G. Troy,& S.L. Mayhugh (Eds.), Managed behavioral health care: An industry perspective (pp. 168-188). Spring-field, IL: Charles C. Thomas.

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A SURVEY OF WHAT CLINICIANS SHOULD KNOW

Discussant: Michael Lancaster

Drs. Shueman and Shore raise several significant issues. Acknowledgingas they do that the survey has methodological limitations, nonetheless itdoes identify trends and raises issues that are important and worthy ofcomment.

A major issue and barrier to the adequate training of behavioral healthclinicians for managed care is the dislike and mistrust by academic centersof managed behavioral health. It appears that many academic centers re-sist giving attention to training pertinent to the new managed health caresystem. It also appears that many managed behavioral health organizations(MBHOs) feel that provider networks can be developed with little atten-tion to training issues and the competence of clinicians to work as pro-viders of care within managed behavioral health.

Academic centers change slowly, while managed behavioral health repre-sents a rapid response to an identified problem. But whether or not man-aged care as we know it today continues to exist, it is imperative that ourtrainees and current providers acquire the competencies needed to flour-ish in the current service environment. It is much too late for academiccenters to wait for the managed care "fad" to pass; it has already changedour system of care irrevocably. MBHOs must assume some responsibility inthis training process as well—both entities must be willing to work to-gether in the interest of good patient care. This paper attempts to focuson specific areas of competency that are perceived as critical in the train-ing process.

The most outstanding and unsettling issue by the survey is that the clini-cian/administrators who responded feel that more than 50% of the clini-cians in their networks lack competence in many of the areas measured.Apparently, the majority of them are judged as not sufficiently competent



to function in a managed care environment; yet they are doing so. Whoseresponsibility is it to train these providers, to do something about whatappears to be a critical problem? As noted by Shueman and Shore, theMBHOs would have to "make an extraordinary investment of resources" toaddress the competency deficits; it is not likely that this will happen. Morelikely will be efforts to develop a more competent general network of clini-cians by identifying through profiling and other means the most compe-tent or those already in the networks and channeling referrals to them.The standards used to judge those most competent are likely to vary fromcompany to company.

The clinician/administrators in 10 out of the 12 MBHOs in the surveyidentify the most critical areas for training as: problem-oriented, goal-fo-cused treatment, development and documentation of realistic treatmentplans; coordination of care with primary care practitioners; and awarenessof community resources. To the extent that MBHOs make clear that clini-cians who have these skills will be in a favorable position with regard toreferrals, the motivation to seek out such training may be enhanced. Andperhaps this will result in a greater availability of the present training.

What clinicians should be trained in seems relatively clear, at least, asdefined by the survey. Who has the primary responsibility to do the train-ing is much less so. It seems to me that remedial programs and formalprimary professional training should occur as a joint effort betweenMBHOs and academic training centers. Such a collaboration could de-velop seminars, provide onsite experiences and include protocols for in-volving trainees in managed care reviews.

The survey refers to "new performance demands for providers" and itappears that the 20 items addressed reflect clear expectations that all pro-viders should be taught these skills as well as the means to employ them. Itis my experience that few clinicians, particularly in private, solo, or smallgroup practices, have in fact operationalized these concepts and skill setsinto their daily practices. I believe that managed care through its oversightand accountability processes and ability to observe what is actually beingdone, as demonstrated, for example, in treatment planning, has helpedproviders to focus their treatment plans. As a result, they are becomingmore effective and efficient. Managed behavioral health is raising seriousquestions about the competence of clinicians and therefore, the adequacyof their training. It is pressing for a higher level of competence (or at leastclarity) in such areas as treatment planning and processes.

As long as most providers are viewed as not prepared to function effec-tively in a managed care environment, MBHOs will continue to exercisecontrol over what they do and how they do it.

The specific areas identified in the survey should become the focus oftraining and retraining efforts of both MBHOs and academic centers.

84

Michael Lancaster

Improved competence by providers will enhance their autonomy, theirability to assume greater control over patient care and perhaps the direc-tion of the health care system. This would alter the role of MBHOs toone of managing a system of care and not the individual providers ofthat care.

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A SURVEY OF WHAT CLINICIANS SHOULD KNOW

Discussant: Laura S. Altman

Based on their survey to identify the competencies that behavioralhealth professionals need to work effectively with managed care, Drs.Shueman and Shore, conclude that all 20 identified competency areas are"desirable in any service setting. . . ."In light of evolving health care andpurchaser trends, addressing and correcting these deficits is urgent, has ashort time frame for accomplishment, and should focus on non-clinical aswell as clinical areas.

While most large and medium sized employers have implemented costmanagement and managed health care programs, managed health careorganizations (MHCOs) have concentrated primarily on increasing marketshare, new product development, mergers and consolidation. However,price pressure on the MHCOs and on providers will continue, requiringthem to focus on lowering costs and utilizing the most skilled, effectiveand efficient professionals.

This discussion highlights key purchaser trends, criteria upon which em-ployers base their health care purchase and retention decisions, and theresponses of MHCOs and managed behavioral health organizations(MBHOs) to these trends. It concludes with a discussion of the implica-tions of all this for behavioral health professionals.

Key Purchaser Trend

Focus on price

MHCO Responses

Major focus on con-trolling costs andachieving competi-tive prices

MBHO Responses

Purchase of grouppractices

Invest in technologyfor improved effi-ciency



When the purchaser is an employer, the focus on price varies by type,e.g., is the employer employee sensitive, employee neutral, or employeeinsensitive? The employee sensitive employer bases part of the MHCO/MBHO selection decision on price. But, the quality of the network, accessand service carry equal weight in the selection decision. An employee neu-tral employer focuses primarily on price but considers the quality of theMHCO/MBHO and of the network. Selection is, however, primarily drivenby price. The employee insensitive employer purchases health care as acommodity. This type of employer selects on price alone.

MHCO AND MBHO RESPONSES

Managed health care organizations and health services in general re-spond to price pressure by instituting various means to control operatingcosts and keep overhead low. They also invest in technology to improveefficiency. Price pressure may also result in passing more risk to providers.As this trend continues, network quality, cost effectiveness and consumersatisfaction will receive increased emphasis including evaluation of treat-ment outcomes, and assessing the quality of care and of the network. Pur-chasers will also pay increased attention to accreditation by externalbodies.

88

Key Purchaser Trend

Increased power ofpurchasers

MHCO Response

Consolidation

MBHO Responses

Share risk with, or capitate theincreasing number of pro-vider groups

The development of purchaser coalitions in health care has fueled pricecompetition. The coming together of similar health plan systems and themerging of dissimilar systems to gain additional competencies, have signifi-cantly changed the health care landscape. The following examples fromjust the past couple of years illustrate the accelerating consolidation, in themanaged behavioral health field:

• Merit Behavioral Care and its new partner, Kohlberg, Kravis, Robertsand Company, purchased Merit from Merck. Merck had purchasedMedCo, Merck's prior owner. Merit, formerly America Biodyne, hadpreviously purchased Integrated PsychCare of Ohio, Assured HealthSystems, Achievement and Guidance Centers of America, Personal Per-formance Consultants and Benesys.

• Magellan Health Services, formally Charter Medical Corporation, anew holding company, purchased Green Spring Health Services and

Laura S. Altman 89

Mentor. Charter had previously acquired Schizophrenia Treatmentand Rehabilitation Inc. Green Spring had previously acquired TAO.

• Foundation Health Plan, which had previously acquired OccupationalHealth Services, also acquired Managed Health Network.

• United Health Care Corporation bought MetraHealth, the owner ofU.S. Behavioral Health.

• Columbia/HCA bought Value Health, the owner of Value BehavioralHealth, that resulted from a merger of American Psych Managementand Preferred Health Care. Value Behavioral Health purchased BurkeTaylor Associates and Health Management Strategies.

Behavioral health professionals in solo practice, still viewed by many asin a cottage industry, are rapidly organizing into groups. Many of themview the assumption of risk as a means to remove themselves from manage-ment by MBHOs. In their quest for autonomy though, many of them areassuming risk before fully understanding how to allocate scarce treatmentresources, manage utilization and build/buy the components needed foran infrastructure. Though they may postpone accountability temporarily,they cannot escape it.

Key Purchaser Trend

Growth in demand forgood information

Information systemsdevelopmentaccelerated for com-petitive advantage

MBHO Response

Technology invest-ments are beingmade to automate,improve efficiency,lower operatingcosts and streamlinecommunications

Consumer report cards will increase in sophistication and importance—not only as an accountability tool, but also, along with the Internet, as ameans of giving consumers more information to better select providersand managers of care.

In fact, information systems, data management, provider profiling capa-bilities and outcomes tracking will be a competitive advantage and differ-entiator for MBHOs in the future.

Key Purchaser Trend

Broad portfolio ofvalue-added prod-ucts

Produce develop-ment inten-sifies

MBHO Response

Mature MBHOs seek to pene-trate new markets (Medi-care, Medicaid, CHAMPUS)

Focus on new products

MHCO Response

MHCO Response


Medicare and Medicaid are relatively new markets for managed behav-ioral health organizations and enrollment has increased. Buyer interest isgrowing and is expected to increase over time.

Key Purchaser Trend

Age of consumerism Accountability/demon-strated results

Service as a healthplan/vendor differ-entiator

MBHO Response

Standards being in-creasingly used toset performancelevels

Use of performanceguarantees aroundservice, access, net-work-quality, qualityof care management

The consumer's role is evolving from partnering with the employer asjoint buyers of health care, into distinct, more sophisticated purchaser en-tities with divergent requirements for health care. Employers look to exter-nal accreditation, NCQA as the standard, to ensure minimum levels ofquality. Consumers are becoming "prospective individual purchasers" fo-cusing on consumer satisfaction ratings, customer service and their per-ception of quality.

The movement towards external accreditation, more consistent creden-tialing standards, and increased accountability, exemplified by perfor-mance standards and measurement for demonstrating accountability areall viewed positively. The following are illustrations of clinical services per-formance targets already put in place by large employers:

• Standard access to an individual practitioner is 20 miles or 30 minutes,and to a facility is 60 miles or 60 minutes. (In rural areas, this may notbe applicable.)

• Clinical Indicator—Care Managers will document level of care deci-sions/rationale that are most consistent with level of care guidelinesfor clinical necessity.

• Clinical Indicator—In denials of levels of care, the rationale for denial,included in the psychiatrist's and care manager's notes, will clearlydemonstrate why the proposed treatment plan falls outside the guide-lines for clinical necessity and appropriateness of care.

• Clinical Indicator—All network readmissions to any 24-hour care facilitywithin six months or less will be reviewed by an M.D. or a clinicalsupervisor with appropriate clinical credentials and experience. In

MHCO Response

Laura S. Altman 91

each case a detailed discharge plan to avoid future rehospitalizationwill appear in the case notes.

• Clinical Indicator—The appropriateness of network based psychoactivedrug treatment and regimen will be evaluated quarterly to determinethat the treatment is achieving the anticipated results and working to-ward a targeted set of goals.

• Clinical Indicator—All network facilities and individual practitionersshall be evaluated on an ongoing basis for appropriateness of care,administrative compliance and adherence to clinical guidelines on anongoing basis.

• Clinical Indicator—Documentation shall be present indicating adher-ence to aftercare follow-up guidelines criteria that show action takenfor each milestone (one, two, six and twelve month intervals) and com-pletions within one month before or after milestone target date.

• Confidential measurement of all members' satisfaction with access toproviders and the vendor's services.

Key Purchaser Trend

Management of qualityof care and servicetakes higher priority

MBHO Response

Behavioral health-spe-cific NCQA criteria

The individual con-sumer: a player inthe equation willhave greater accessto information, in-cluding the Internet,and will demandmore of health careproviders

In 1996, to help consumers select physicians and health plans, the Mas-sachusetts Medical Society and Board of Registration in Medicine imple-mented physician profiling. Consumers call the Society who screens andrefers the caller to the Board of Registration. Consumers can obtain thefollowing information about any physician:

• How long the physician has been licensed• Current address• Current hospital affiliations• Insurance plans accepted• Are new patients accepted into the practice?• Is Medicaid accepted?

MHCO Response

• Physician's education, training and specialty• Certification in the specialty

Optional information that physician can supply:

• Honors and awards received• Professional publications• Malpractice Information• Paid liability claims or settlements in the last 10 years• Disciplinary actions been taken in the last 10 years. If yes:

By a hospital?By the Board of Registration in Medicine?Other

IMPORTANT NON-CLINICAL COMPETENCIES

Employers constitute a major purchaser segment, and they expect prac-titioners to understand the meaning and implications of benefit plans, tobe able to utilize all relevant available benefits, and be sensitive to workplace issues. From the MBHO's perspective, this understanding is criticalto providing cost effective care.

In an employer-environment of "manage care rather than limit bene-fits," all benefit design features available should be used. In the sampleplan below, those features that are clinically appropriate for several typesof disorders, are cost-effective and useful but rarely used are in italics.

Incentive copayments for outpatient care can be used in a combinedEAP and managed behavioral health program. Employer consolidation ofthe EAP and managed behavioral health benefits is occurring widely.There are administrative and cost efficiencies, as well as ease of administra-tion in working with only one administrator.

From the enrollee's perspective, the one to four visit outpatient benefitwith no out-of-pocket costs, reduces barriers to access when in-networkcare is used. It allows for maximization of the different types of servicesavailable in the EAP and mental health network so that referrals can bechanneled to the clinician with the most appropriate skill set, without in-fluence by economic incentives.

Group therapy, the other benefit in this sample plan that is not oftenused even when it is clinically the treatment of choice, is a reduced copay-ment. Note that this is a very open outpatient benefit plan with no visitlimit.


Laura S. Altman

IMPLICATIONS FOR PROVIDERS

As integration and consolidation continue, there is the potential offewer practice opportunities for behavioral health professionals due tomore closed provider network models (e.g., EPOs), more salaried posi-tions, streamlined networks and removal of those practitioners unable tomeet increasingly rigorous standards of practice.

All these trends underscore the abbreviated time frame for practitionersto address and correct current skill and knowledge deficiencies. The acqui-sition of these, plus new competencies not yet fully defined but likely to berequired in the future, will be critical for practitioners to succeed andperhaps survive in an increasingly rigorous managed care environment.Purchasers and managers of behavioral health care well recognize that thecompetence of the clinicians in the networks is not enhanced, a majordeterrent of the quality of care.

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Documents

A survey of what clinicians should know