This article was downloaded by: [University of Louisville]On: 19 December 2014, At: 16:00Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

Journal of Couples TherapyPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wzct20

How Managed Care Can HelpCouples CopeJames M. Shulman PhD a ba Behavioral Health of Mount Carmel Health System ,b Mount Carmel Behavioral Healthcare Company ,Published online: 15 Oct 2008.

To cite this article: James M. Shulman PhD (1999) How Managed Care Can HelpCouples Cope, Journal of Couples Therapy, 8:3-4, 75-86, DOI: 10.1300/J036v08n03_07

To link to this article: http://dx.doi.org/10.1300/J036v08n03_07

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How Managed Care Can Help Couples Cope

James M. Shulman

SUMMAHY. 'Ihis article traccs how managed cart: bccamc a quick fix to curb out-of-control hwlthcarc costs rather than a rcal cffective ap- proach to managing a r c . To date, the impact has been not only a negative expericncc, but impediment to treating couples facing rcla- tionship and rclatcd problems. Thc author is optimistic about how rnan- agcd carc will evolvc to rccognite the importance of couples and family trcatment as we enter thc future with intcgratcd systems of healthcare. Thr futurc will also require significant shifts in thc thinking and prac- tice patterns of providers ond an cmphasis on quality and outcomes. [Arricle copies mwiluhlr [or u fee from The Huworrlr Docrinietii Delivery Service: lfffW-342-%78. E-muit addms: g a i ~ ~ ~ t u w o r ? l r p ~ s b c . c w n < Web- sire: hrrp:llwww.liu worrlipr~essiric.cor~i> ]

KEY WORDS. Managcd care, bchavioural health carc, Rcimhurse- ments, intcgratcd delivery systems

IN TROD U CTION

When I was asked to addrcss how managed carc can help cauplcs cope, my first thought was this will only take a paragraph. Managed

Jamcs M. Shu lman , PhD, ib Vicc Prcsideni, k h a v i o r i l Health of Mount C5miel Health System aiid Chief Executive Officer of Mount Carmel Behavioral Heilthwn Company, R multi-disciplinary outpatient behavioral healthcare practice with over 50 fu I I - t i mc c I i II ic ians .

(Haworth co-iridcxing m i r y nacl: "How Mlanagsd C.irc Chn I lclp Cuuplrs Copc." Shlllmn, James M. CJ publkhed simultai~ously in J o r ~ ~ ~ r u l of C~mplr..~ 7lfr.rapu (l'hc I iaworih Pmss. lnc ) Vnl. 8. No. 314. 1W9. pp. 75-86. and: Cniipks Thrrapv iii Alorqtyd Care: t'ncirig die Crisis (ed. Barban Jn tlrc4hcn) The l l iwonh Prrrs. IIIC.. 1999. IT. 75-M. Sinfik u rnulriylc q ~ c s nlthls m i c k arc avuila& iu a fet fmm Thc Hvwunli Dumixnl Dclivcry k r v i c x [ IW-342-9678. 9 - M a m . - T:(KI y m . [W'l'). E-liwil actlrrw: gelillio@ hwmhpressi iwxni j .

1 W Y by The Haworth Press, Inc. 1 \ 1 1 rights reservctl. 75

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76 COUPLES THERAPY IN MANAGED CAW

care, as it has been practiced in the last ten years, has tried to avoid providing services to couples. I am optimistic that this will change and that new opportunitics will evolve for therapists who have expertise in couples and family treatmcnt. This article reviews: (1) the reasons that managed care approaches have doniinated behavioral healthcare ser- vice defivcry in recent years; (2) why or how managed care has short- changed couplcs, and; (3) the new opportunities that will dcvelop to serve couples.

THE REASONS MANAGED CARE APPROACHES H A VE DOMINATED

BEHAVIORAL HEAL THCARE SERVICE DELIVERY

From the 1960s until the mid- I98Os, psychiatrists, psychologists, social workers, marriage and family counselors, and other profession- als grew in number and public acceptance. During this time most States enacted laws in licensing most of these professions and many also passed laws mandating insurance coverage for menfal health vendors (Winegar, 1992). Where vendorship was not mandated, most States allowed psychiatrists and/or psychologists to supervise other professionals for insurance reimbursement. As independent practition- ers prolifcratcd, so did mental health services and the volume of insur- ance claims and third-party paynicnts. Following lcgal mandates, in- surance payors began covering outpatient mental hcalth counseling services as well as inpatient treatment. Until the mid-1980s these payors barely Scrutinized services provided or claims paid. Conse- quently, without any review by payors, practitioners and ireatment agencies experienced an “Age of Freedom” in healthcarc rcimburse- ment (Shulman, 1993). For practitioners treating couples, insurers reimbursed a number of diagnoscs described in the American Psy- chiatric Association’s Diagnostic and Siarisrical Marirral, Vohrne I1 (DSM-II), with 7’ransient Situational Disturbances (7SD)lAdjustrnent Disorders used most frequently. With the introduction of a revised diagnostic manual, e.g., DSM-III, thosc diagno.ws which wcrc used for reirnbursemcnt of couples treatment were no longer considered “true mental health” categories and were made into “V” codes which insurers began to exclude from reimbursement, Many practitioners quickly learned to bill under other less appropriate mental health diag- noses as the only way to receive insurance coverage for treating cou-

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Jurnrs M. Skulntun 77

ples. At the same time that outpatient providers Iearned thc new rules of reimbursement, inpatient providers a l so learned a number of “tricks of the trade.” By the mid-l980s, the country saw an explosion of hospital programs for alcohol/drug treatment and psychiatric carc which were designed around 30-day stays, the magic number that most insurers would cover.

Unfortunately, during this “Age of Freedom” abuses such as fraud- ulent billings and unnecessary treatment services became too frequent (Moder-it Ifeulrhcare, 8/4/97). For example, i n the mid-1980s with uncontested insurance rcimbursernent, there was a rapid proliferation in the number of inpatient adolescent psychiatry units throughout the U.S. that marketed programs to parents and encouraged them to admit an unruly adolescent for a short reprieve and the expense of the par- ents’ insurer. Between 1982 and 1986 the number of adolescents in the U.S. declined, but the incidence rates for their hospitalization wcnt up 350% (Winegar, 1992). While inpaticnt providers were more obvious targets for abuse investigations, outpatient providers also came under greater scrutiny by payors for purported overutilization, potential abuse and weak or poor standards of practice (Feldman, 1992 and Austad, 1996).

In 1988 and 1989 the author’s private practice was contracted by a number of major insurers to review outpatient claims and services of mental health/alcohol/drug providers. In rcviews some of the ques- tionable practices that we found included:

Over a third of thc providers who requested reimbursement did not have clinical or chart records with such basic information as a diagnosis, treatment plan, or progrcss notes for each session which are basic standards for good practice; Some non-medical clinicians had patients returning to see them weekly for as long as five ycars with no indication of any im- provement in functioning. Reviewing psychiatrists found that many of thcse patients were diagnosed as depressed and had nev- er been considered for or evaluated for antidcprcssant rnedica- t10n; Clinicians often used unsubstantiated diagnoses to meet insur- ance requirements and would change diagnoses if the original ones were not reimbursed;

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Many psychiatrists and psychologists werc “selling their signa- ture” to unlicensed, some non-degreed, practitioners by signing insurance forms as a supervisor €or the patients when they (the supervisors) knew nothing about thc patients; Many clinicians would waive co-payments and then fraudulently bill insurers for larger fees to cover patient services.

These type of activities along with the abuses by inpatient practices all contributed to thc growth in healthcare costs affecting crnployers and insurers which lead to this country’s recognition of a healthcare crisis in the late 1980s. The crisis .set the stage for employers and insurers to create “managed care.”

“THE ILEiGN OF TERROR”

Thc “Age of Freedom” for providers came to an end in the late 1980s. The healthcare (payer) industry shifted to thc new paradigm of managed care. Traditional health insurance or indemnity plans soon created new delivery systems that included llealth Maintenance Orga- nizations (HMOs), Preferred Provider Organization (PPOs), Indepen- dent Practicc Associations (IPAs), Point of Service Plans (POS), and may other “alphabet models” of managed care. The original purpose of managed care was to develop a coordinated approach to the design, financing and delivery of health care. The goals were set to balance price and utilization controls with access to high quality care. Managed care plan designs specifically included such elements as limited access to providers, employment of utilization controls, higher levels of bene- .

fits available for “in-network” services, quality of care controls and the mutual establishment cost/utilization targets with employers and pro- viders. Despite thc original intent of managed care plans, much of the initial efforts by insurers and their agents really focused on managing costs and rationing care rather than on managing care.

By 1990 thc “Age of Freedom” for providers or providers shifted to the “Reign of Terror” (Shulman, 1993) where providers felt terrorized by payers, and what was called managed care was more: often described as mismanaged or “mangled” care. Payers and their agents cut fecs, held providers hostage to contract language, e.g., with gag rules, denied care, outright refusal or delaycd payments and threatcned providers who would not follow rules. ’ h i s was particularly evident in the mental

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James M, Shultiiarr 7Y

health and chemical dependency (MH/CD) treatment arena when payers “carved out” MHKD treatment and bankrolled a whole ncw industry, i.e., managed behavioral healthcare. Early players applied the same techniques of utilization review and managed care plans as were being used in medical care and soon dominated the market of MH and CD treatment invcnting a new label, i.e., behavioral healthcare. Provid- ers no longer had the freedom to treat individuals, couples or families, without a “big brothcr” looming overhead, indicating what would or would not bc covered. More was not covered rather than covered in most cases. Managed behavioral healthcare organizations initially se- lected the most inexpensive providers and facilities which demonstrated the bricfest treatments independcnt of outcomcs. Treatment was meted out on the basis of session-by-session or minimal numbers of sessions or inpatient days followed by “micro-managcment,” i.e., cumbersome paper and adversarial tclcphonic reviews. Recause the initial plans for HMOs, PPOs, or other types of self-insured plans, uscd the industry standards for Covered service and exclusions used by traditional indem- nity insurance plans, the benefits offered were as limiting as they were with non-managed care insurance companies. One improvement was that exceptions began to be made for intermediate care levels of treat- ment (day treatment, inteilsive outpatient groups, structured group pro- grams, etc.) which insurers prcviously did not reimburse. Trade-offs of inpatient days for two or three day treatment days began to be written into new plans. However, in the treatment of couples, there was cven less emphasis placed on looking at the whole family or couplc. than had been under the old DSM ?SD diagnoses. Managed care plans were much more skeptical about thc rcasons for couples approaching treat- ment and became even more rigid using the insurance standards that said couples’ treatment was not a covered benefit. As noted earlier, many clinicians became shrcwd and savvy and learned to define cou- ples’ treatment under thc classification of an identified patient and would use a legitimate or reimbursable diagnosis. Individuals were able to obtain some couples’ treatment with half of the couple k i n g part of collateral visits. Where this was not easily accomplished, couplcs would become more frustrated with their insurance plans and the man- aged behavioral health care tirms as authorizations and reimbursement for couples serviccs would be denied. This becamc true for may other similar problems, e.g., requiring a family or parent-child treatment. ’The frequent denials for coverage put additional stress on couples and fami-

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lies. Many providers resenting managed care intrusion inappropriately egged paticnts on by cncouraging vigorous protest to cmployers and payers and by “badmouthing payers.” Unfortunately, managed behav- ioral health care plans had .some legitimacy in distrusting providers as many rcmained unfocused on their treatment, continued unnecessary utilization, kept poor or no (legally required) records and acted as if insurance coverage was a entitlement. The end result of managed care has left some individuals with untreated problems which in fact could lead to more serious emotional disurders, domestic violence, abuse, medical conditions, etc. Inciting patients also added stress to those who were able to get some authorizations for treatment. Many providers did learn to turn “lemons into lemonade” by cither adopting more focused forms of treatment and/or developing non-insurance rcirnbursablc pro- grams to help individuals with couple, stress, work and other problems. Providers also developed Employee Assistance Programs (EAPs) which offer altemativcs to insurance and strict interpretations of bcnefits. With many EAPs couples could have help in coping and not have to battle with managed care firms. In sum, managed care (itself) has not directly assisted most couples in their coping. However, unintentionally it has helped couples by setting the stage for some providers to become more focuscd in treatment. Many other providers who just couldn’t work with managed care entities have also bccorne entrepreneurial and deve1- oped alternatives such as EAPs, weekend couples’ retreats, special educational programs, and a varicty of other approaches with sliding fee schedules designed to help couples who can’t afford costly 1:l sessions.

CRYSTAL BALLING THE FUTURE: IS THERE LIFE AFTER MANAGED CARE?

The future holds a number of “good news, bad news” scenarios for providcrs as well as patients, especially couples. The first bad news is that due to the increased competitiveness of managed a r c entities in thc private sector things will be worse before they’ll get better. Major players continue to fight for market share. The surplus of providers in the markct place rnakcs it even easier for managed care firms to contin- ue to lower reimbursements. Some providers are actually being forced out of business, unable to earn a living. By the year 2000 Nicholas Cummings, Ph.D., grimly predicts that 50% of current psychotherapists

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Juines M. Slrulmari 81

will be out of business (Cummings et al., 1996). Competition has re- sulted in many firms continuing forms of terrorism. However, the first good news for providers i n the private sector is that for these firms to remain competitive and profitable, there is vcry little room left for them to grow and the payers are also squeezing them financially. As a resiilt of decreasing profits, losses and lack of growth opportunity, the largest managed care companies have turned toward the public sector for fu- ture growth and development. In the public scctor state governments are developing carveouts which are designed for managed behavioral healthcare companies to operate the statewide Medicaid programs. Un- like in the private sector where huge profits and denial of services was largely unchecked by payers, the public programs do havc limits on profitability and specific service targets. There is opportunity for profit- ability, but with greater built-in controls. For couples and fanlilies who are covered by Medicaid, the good news is that thcre may be greater opportunities for assistance and service than in a non-managed system. ’Ihe bad news is for the private provider who treats or would like to treat Medicaid recipients. Without some connection with a publicly funded agency, c.g., community mental health center or hospital entity, there may be fewer opportunities. In most states with Medicaid man- aged care, the managed care organizations have partnered with or con- tracted with the large community agencies for services. The more these agencies are doing i n the managcd care arena the tougher the compcti- tion will be for providers in general. Throughout the country, publicly funded agencies with managed care know how are vying for private sector business. Many agencies are attractive to payers as they offer a larger array of services than independent providers. For providers who don’t align themselves or contract with public funded agencies, there are still some, but limited, opportunities for longer term survival as noted earlier. For the patients such as couples seeking help, there may even be more opportunities. That’s good news, but the bad news for independent providers is that they’ll lose much of their autonomy, work fur othcrs and will have to work much smarter!

IN TEGKATED DELIVERY SYSTEMS

Throughout the country, managed care has set the stagc for medical carc providers to dcvelop less cxpcnsive, higher quality and more integrated delivery systems. Venturcs or partnerships between hospi-

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tals and physicians and sometimes even with payers, are rcsulting in reimbursements and incentives being better aligned. More eflcctive application of new technologies, the use of advanced computer sys- tems and the provision of more responsive, accessible care, suggest that thcse new ventures are preparing for the future. Many of the hcalthcare systems have true partnerships between individual provid- ers and hospitals and in others the healthcare systems have developed or acquired specialty care providers including mental health and alco- hol/drug agencies and individual providers. These for profit and not- for-profit integratcd health delivery systems are cautiously developing their own capabilities to cnter thc market place as competitors to the managed care entities that grew from insurancc firms in thc 1980s and 1990s. In a number of urban markets employers have developed pur- chasing allianccs which bypass insurance owncd systems and directly contract with these emerging provider systems. These systems c a n reduce administrative costs and profit margins and also offer more divers and integrated services at lower costs than payers. Some sys- tems have chosen to work tighter with the payers and avoid potential business loss through perceived or real Competition with the payers. These provider systems negotiate preferred or exclusive arrangements with payers and seek partnerships that both focus on quality and align incentives through risk sharing models rather than accepting lower and lower fee-for-service amounts. In the behavioral health arena systems negotiate case rates to provide all serviccs for certain diagnos- tic groups or agree to subcapitation rates for behavioral health scr- vices, Driven by the accreditation standards of the National Commit- tee for Quality Assurance (NCQA), payers are seeking the providers who can best meet the standards, demonstrate quality or performance improvement, can service the whole patient and at the same time can provide required data and reports to support these efforts. In the future those providcr based health systems that can also meet specific NCQA behavioral healthcare standards, are prime €or delegation of care by payers and managcd behavioral healthcare entities rcquired to meet such standards. This is welcomed good news, i.e., more local provider control in clinical delivery will someday return. The not so good (but not so bad) news is that t h e indcpendent or private providers wiIl have to become a part of these systems. For participation providers will need to stop wasting encrgy by “whining about !he evils of managed care” and must direct i t to practicing focused or targeted treatment,

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perfccting niche practice areas that minimize costly care, developing the ability to track positive outcomes and demonstrate client satisfac- tion, and quality of care (as rcflected in JCAHO and NCQA stan- dards).' Locally based intcgrated delivery systems can't afford the timc, cost and effort to spoon feed standards of care or criteria to independent providers. It is up to the providers to obtain the standards, read and adopt them. The payoffs in .being a part of an integrated delivery systcm is that patients can receive bctter care with the atlcn- tion directed to both behavioral and physical hcalth care. As the next century approaches, more emphasis will be placcd on the role behav- ioral healrhcare provides in general medical healthcare and how cffec- rive behavioral hcalth interventions and approaches can, in fact, im- pact the escalating cost of medical care. How docs the movc to quality integrated delivery systems help couples copc better?

HELPING COUPLES COPE

As fully integrated systems develop, wlicther partncrships between providcrs and hospitals, or hcalth systems run by hospitals, or systems owned by other healthcare entities, the opportunities will be available for treating couples as whole families or treating the whole person which will result in the best overall healthcare. While these newer healthcarc systems gain strength and go aftcr insurance business and/ or private employer business as well as public sector business, they can offer a completc package of all services at rates which are attrac- tive to the payers. As provider incentives or reimbursement systems move to capitation and subcapitation models where a full amount of money is paid i n advance each month for each covered member or covered life, then the budgeting process of where dollars get put in treatment becomes thc responsibility of the fully integratcd system. In such a system, the early identification of individuals and couples having behavioral problems that could lcad to more costly healthcare or mental healthcare becomes the primary goal for longer term niedi- cal or treatment cost savings. As rcsearch has shown, stress and behav- ioral dysfunctions can lead to or exacerbate medical conditions; it only makes scnsc that early behavioral interventions offered in a single provider based health system will be uscd to prevent more. serious medical problems. I n this future-oriented, quality based and integrated care paradigm, physicians or othcr providcrs in the medical system

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can identify individual and couples problems and quickly rcfer them (without worrying about extra costs) within the system for resolution by a behavioral health professional. Sharing in cost savings, physi- cians and the health system are better incentivized for appropriate iiivolvemcnt of behavioral hcalthcare. Thus, in thc fully integrated system, couples will bctter be able to cope, if all of their healthcare and relationship problcms that can precipitate more serious health problems are handled by an organization that is at-risk for all of the care for the individual. I n many parts of the country there has been rapid development of integrated delivery systems that offer all care from birth of an infant to providing senior nursing/medical care within the same system. Independent providers who will be practicing in ten, fifteen o t twenty years need to devclop an alignment with an inte- grated delivery system in order to be involved in both public and private sector funding in the future. For continuation uf reimbursed treatmelit to better help couples cope in the future such participation is essential. There wiIl always be opportunities for some providers who choose to seek patients who will self-pay for services, but with the surplus of providers the competition will be far too great for most to survive. For many paticnts the cost of couples’ treatment without benefit coveragc adds an additional financial strain on whatever stresses are already contributing to the couple’s problems. In the fu- ture, an important screening tool will be used by physicians (or other entry point individual professionals) who first see patients, couples or families at the first point of contact. With such screening, referrals will quickly be made to a provider who can treat the problems, whether or not the presenting problems are those that meet “reimbursable” diag- noses. To sum, with the “one stop” shopping in a fully integrated system, the opportunities to help couple’s cope would be greater with- out any additional financial or other stresses put on the couple. In addition, traditionally, non-reimbursed preventive or educational sup- port programs will be more available as they can result in greater savings in treatment costs to the singlc system.

CONCL USlON

Managed care as it is now practiced, is an incredible stressor to individual providers and patients alike. Professional organizations and providers continue to complain about managed care of the present and

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NOTE

I . Standards are available from NCOA, 2000 L. St. NW. Sfe SO. Washingtun. D.C. 20036 and JCAIIO, One Renaissance Boulevard. Oak Brook ?’errdue. Illinois 60181.

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