Annotated Bibliography - Provider Issues

This special supplementary section of the bibliography provides an independently produced annotated bibliography on managed behavioural healthcare prepared for the US Substance Abuse and Mental Health Services Administration; please see the first page of the supplement for recommended citation information.

Table of Contents

  1. Introduction
  2. Benefit and System Design
  3. Capitation
  4. Community Mental Health Services
  5. Diagnosis-Related Groups (DRGs)
  6. Economics, Forecasting, and Pricing
  7. Employee Assistance Programs (EAPs)
  8. Health Maintenance Organizations (HMOs)
  9. Law and Ethics
  10. Provider Issues
  11. Public Sector
  12. Quality Assurance and Outcomes
  13. Special Populations
    1. Children
    2. Elderly
    3. Ethnic Groups
    4. Women
  14. Substance Abuse
  15. Training and Education
  16. Utilization Management
  17. Author Index
  18. Keyword Index

Provider Issues

206. Armenti, N. P. (1991). The provider network in managed care. The Behavior Therapist, 123-128.

This article describes the characteristics of providers who might be most successful in a managed care system. These include having substance abuse training and experience; the ability to provide emergency and crisis intervention; behavioral training; a demonstrated ability to use community resources; and a community mental health or agency background. The author describes some of the varying styles of managed care for providers and suggests that providers also need to be selective when choosing a managed care arrangement to join.
Keyword: providers

207. Austad, C. S., & Berman, W. S. (1991). Managed health care and the evolution of psychotherapy. In C. S. Austad & W. H. Berman (Eds.), Psychotherapy in managed health care: The optimal use of time and resources (1st ed., pp. 3-18). Washington, DC: American Psychological Association.

This chapter, written by the book’s editors, describes how the changing health care system has impacted the field of psychotherapy. They examine the evolution of short-term therapy, and describe the commonalities in all of the therapies practiced in managed care settings. Psychotherapy as it is practiced in the HMO setting is discussed, as are controversies in and about managed health care.
Keywords: providers, psychotherapy

208. Austad, C. S., Sherman, W. O., Morgan, T., & Holstein, L. (1992). The psychotherapist and the managed care setting. Professional Psychology Research and Practice, 23, 329-332.

This study explores the practice patterns and attitudes of 43 mental health professionals working in staff-model HMOs in the Northeast. Participants were asked to respond to semi-structured and open-ended questions about their work setting, burnout, graduate training, and the evolution of their practice style. Therapists were found to "happen" into the HMO setting and to possess little information about HMOs prior to their employment. Participants reported that their work involves a high level of direct client contact, that they use mostly brief therapy methods, and that they use a variety of strategies to prevent burnout. The study also discusses the ways in which psychologists differ from other mental health professionals in their practice styles.
Keywords: providers

209. Backlar, P. (1996). Managed mental health care: Conflicts of interest in the provider/client relationship. Community Mental Health Journal, 32(2), 101-106.

This article is a theoretical analysis of the conflicts of interest confronting health care providers with special attention paid to mental health providers and the implicit economic conflicts of interest brought about by managed care. According to the author, there are three primary posi-tions where conflicts of interest arise in health care: when providers promote their clients’ interests over all other interests; when providers promote the general social good by acting as rational resource allocators; and when providers promote their own financial well-being at the expense of all other interests. The author argues that conflicts of interest in managed mental health care are distinct from those that arise in traditional health care services because the mentally ill population oftentimes has a limited ability to care for itself or to make informed choices. Therefore, the author sees a potential loss of confidentiality in patient care for people with mentally illness, as well as a potential conflict between the provider’s personal financial loyalties and the patient’s interests.
Keywords: ethics, providers

210. Baker, N. J., & Giese, A. A. (1992). Reorganization of a private psychiatric unit to promote collaboration with managed care. Hospital and Community Psychiatry, 43, 1126-1129.

Over the past five years, an increased number of managed care organizations in the Denver, Colorado, area have challenged psychiatric hospitals to reduce costs and length of stay. This article describes the experience of one private psychiatric hospital unit that reorganized a locked unit into three progressively less restrictive ones through which patients could progress at their own rate. In the first year after reorganization, length of stay and staffing costs were significantly reduced. This article describes these and other impacts of this hospital-based alternative model.
Keywords: models, providers

211. Barnes, P. D. (1991). Managed mental health care: A balancing act. Administration and Policy in Mental Health, 19, 51-55.

Managed mental health care is characterized by tensions between countervailing interests, goals, and approaches. In this opinion piece, the author identifies some of the areas in which mental health professionals are working to strike a balance, and the implications of the choices that they make. Managed care companies’ desire to use a selected panel of providers must be balanced against consumer freedom of choice; quality control must be balanced against the need to control costs; utilization review must serve providers, consumers, and payors alike; and mental health goals must be balanced with health care goals. After describing these tensions, the author outlines methods to reduce adversarial relationships, arguing that the behavior of managed health care and practitioners will eventually become more similar and collaborative.

Keyword: providers

212. Bennett, M. J. (1992). The managed care setting as a framework for clinical practice. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 203-217). Washington, DC: American Psychiatric Press.

The author describes a treatment model for psychotherapy in a managed setting that was developed with over 20 years of experience in an HMO environment. The treatment model, referred to as focal psychotherapy, consists of five phases that can be characterized along six axes. This treatment model is described, as are the implications of this model for assessment and monitoring client progress. The author argues that this model is responsive to patient needs as well as cost-effective. He asserts that although the focal psychotherapy originated in a closed setting, the model is compatible with a wide variety of clinical settings with similar missions.
Keywords: models, providers, psychotherapy

213. Berkman, A. S., Bassos, C. A., & Post, L. (1988). Managed mental health care and independent practice: A challenge to psychology. Psychotherapy, 25, 434-440.

This article addresses ways in which high quality of care can be delivered within a framework that emphasizes cost-containment. The authors outline the key strategies of the Synton Group, a mental health management firm. These strategies include diagnostic consultation; utilization management committee; and use of patient satisfaction surveys. The article describes critical issues that managed care systems should consider: using experienced providers; meeting both clinical and financial goals; establishing effective mechanisms to ensure access to care; and matching patients with providers and treatment. The authors also discuss the various arrange-ments between managed care firms and providers, and their advantages and disadvantages. Finally, the article reviews questions regarding what constitutes effective mental health treat-ment, and the role of diagnosis in such treatment.
Keywords: managed behavioral health care organizations, providers

214. Berman, W. H., & Austad, C. S. (1991). Managed mental health care: Current status and future directions. In C. S. Austad & W. H. Berman (Eds.), Psychotherapy in managed health care: The optimal use of time and resources (1st ed., pp. 264-278). Washington, DC: American Psychological Association.

This chapter, written by the book’s editors, provides an overview of the book. The authors write that the purpose of the book has been to "describe optimal mental health care as it is practiced by clinicians in managed health care systems." The collection of chapters demonstrates the vari-ous ways that psychotherapists have adjusted their practices to accommodate changes in financ-ing and organization of the mental health care system. This chapter summarizes some of the innovations in theory, assessment, and treatment and explores current developments in program development, treatment of chronic patients, and training and staff development.

Keyword: providers

215. Bittker, T. E. (1992). The emergence of prepaid psychiatry. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 3-10). Washington, DC: American Psychiatric Press.

This chapter briefly describes the emergence of prepaid psychiatry over the past 25 years, from its beginnings in the HMO movement of the 1960’s to its recent forms of managed care. The author argues that physician surpluses and escalating medical care costs have promoted an alliance between government, corporate America, and health insurers that has led to an industrialization of medicine. He describes the impact of this industrialization on mental health professionals and discusses the ways in which changes in the financing and organiza-tion of psychiatric services will continue to impact psychiatry in the next century.
Keywords: overviews, providers, trends

216. Carson, D. (1993). Managed care: A provider perspective. New Directions for Mental Health Services, 59, 81-87.

This chapter uses the experience of a private psychiatric hospital to describe the impact on both the hospital and its staff of moving towards a managed care model. As in other psychiatric hospitals, managed care led to a shift in focus from inpatient to outpatient care. In addition to the impact on locus of care, there was a concomitant impact on length of treatment, type of treatment, and range of services offered to clients by the hospital. Moreover, managed care had a profound impact on clinicians. A detailed case example describes the initial problems experienced by the hospital and staff, changes in staff attitudes, administrative issues, financial issues, and the vision for the future.

Keyword: providers

217. Dewan, M. (1999). Are psychiatrists cost-effective? An analysis of integrated versus split treatment. American Journal of Psychiatry, 156, 324-326.

Recent models of health care have emphasized the need to treat the patient holistically, inte-grating behavioral health services and physical health services under one managed care organi-zation. Yet within the realm of mental health, many health maintenance organizations (HMOs) favor split treatment between psychiatrists and psychotherapists over integrated care by a sin-gle provider because they assume split treatment will be less costly. In this study using 1998 fee schedules from seven large managed care organizations and Medicare, the author models clini-cal scenarios of psychotherapy alone, medication alone, and the combined treatment provided by a psychiatrist or split with a psychologist or social worker. From the results, short-term psychotherapy alone by a social worker is the least expensive modality. For patients who require more intensive treatment, integrated care is less expensive than split treatment for almost all treatment length scenarios. The author argues for further research to differentiate patients who will respond better to brief psychotherapy alone compared with combined treatment.
Keywords: costs, integration, models, providers, psychotherapy

218. Dial, T. H., Bergsten, C., Haviland, M. G., & Pincus, H. A. (1998). Psychiatrist and nonphysician mental health provider staffing levels in health maintenance organizations. American Journal of Psychiatry, 155, 405-408.

Based on research from the Group Health Association of America (now the American Association of Health Plans) concerning clinical staffing patterns in a sample of staff and group model health maintenance organizations (HMOs), this study examines the ratios of full-time psychiatrists to members and nonphysician mental health professionals to psychiatrists. From the results, the overall mean number of psychiatrists per 100,000 HMO members is 6.8, and there are 4.5 nonphysician mental health professionals on average for every licensed psy-chiatrist in the plan. Compared to previous estimates of the required psychiatrist-to-population ratios in fee-for-service and managed care environments, the overall number of psychiatrists per 100,000 members is less than half the requirement for a fee-for-service environment esti-mated in 1980 and about 40-80 percent greater than that for a managed care environment estimated by later studies. The authors argue for the need of adequate projections of the future demand for psychiatrists and suggest potential mechanisms to aid in this analysis.

Keyword: HMOs, providers, staffing

219. Dörken, H. (1994). Managed care intervenes where state regulation fails. In S. A. Shueman, W. G. Troy, & S. L. Mayhugh (Eds.), Managed behavioral health care: An industry perspective (pp. 113-126). Springfield, IL: Charles C. Thomas.

In this chapter the author argues that managed care has brought the issue of clinical standards, quality of care, and accountability to the fore. He discusses the inadequacies of regulatory enti-ties to ensure competency among mental health providers and to maintain reasonable practice standards through peer review. He reviews licensing and other legislation in the state of California to demonstrate the inability of such legislation to regulate professional behavior.
Keywords: California, legislation, providers

220. Dorwart, R. A. (1990). Managed mental health care: Myths and realities in the 1990s. Hospital and Community Psychiatry, 41, 1087-1091.

As managed mental health care is becoming the norm for people who are insured, concerns about the effects of managed care are increasingly being raised by both clients and providers. These concerns have focused around whether managed care really reduces costs, whether it adversely affects the quality of care, and the ways in which it affects access to care. The author calls for more and better research to answer some of these questions and debunk some of the myths about managed health care. This research would ideally lead to better communication between mental health professionals and managed care organizations.

Keyword: providers

221. Feldman, J. L. (1992). The managed care setting and the patient-therapist relationship. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 219-229). Washington, DC: American Psychiatric Press.

This chapter delineates five major aspects of managed care practice that influence the patient-therapist relationship. These are payment, systems issues, regulatory issues, internal manage-ment issues, and organizational values. The author discusses each of these issues in a managed care setting. She argues that the overall values and philosophy of an organization will signifi-cantly impact the therapeutic relationship. She presents a model of the therapeutic relationship as a "family triad" of patient, therapist, and organization, and asserts that alliances between any two of the parties will impact the quality of the relationship between the patient and the clinician and inevitably affect the outcome of therapy.
Keywords: overviews, providers

222. Feldman, J. L., & Fitzpatrick, R. (Eds.), (1992). Managed mental health care: Administrative and clinical issues (1st ed.). Washington, DC: American Psychiatric Press.

 This book includes articles about managed mental health care from administrative as well as clinical points of view. The book is divided into three sections: administrative issues (covering the historical, economic, and managerial approaches to managed care); clinical issues (often using a case study approach to discuss treatment approaches developed by the authors); and a special issues section. Two chapters in the clinical issues section focus specifically on managed care services for drug and alcohol abuse. In the final section on "special topics" are articles discussing new delivery system approaches, including one that describes a computer-assisted therapy method for short-term therapy.
Keyword: providers

223. Fowls, D. J. (1994). From managed care to cooperative care. Managed Care Quarterly, 2(2), 46-50.

The tensions between managed care companies and providers of care have led to what this author calls "organizational schizophrenia." This article addresses some of the reasons for the lack of communication and cooperation between many providers of mental health care and the managed care companies they work for. Two case studies are presented in which providers and managed care companies have moved beyond a conflictual relationship to form a collaborative one. The author argues that this can only happen with leadership from both camps and a shared vision of quality and cost-effective care that puts the consumer and provider first.
Keyword: providers

224. Goldstein, L. S. (1989). Genuine managed care in psychiatry. General Hospital Psychiatry, 11, 271-277.

In this article, the author describes a genuine managed mental health care system and the role of psychiatrists in such a system. Genuine managed care is defined as a practice pattern that mental health practitioners can use to deliver quality care cost-effectively. Practice pattern is a structure for care, and includes provision of multiple services by a multidisciplinary staff. It is also a process characterized by collaboration, utilization review, and quality assurance. The author concludes by presenting an evaluation study analyzing the use of such a practice pattern by a group practice.
Keyword: providers

225. Goodman, M., Brown, J., & Deitz, P. (1992). Managing managed care: A mental health practitioner’s survival guide. Washington, DC: American Psychiatric Press.

This book is written specifically for mental health practitioners who may need help under-standing their evolving role in a managed mental health care system. It is intended to guide the clinician through the review processes inherent in managed care services and to help them develop appropriate treatment plans. The authors use clinical vignettes to illustrate how to write patient impairment profiles and outcome objectives. In lengthy appendices, they provide specific psychotherapeutic interventions for many common mental disorders.
Keywords: providers, technical assistance

226. Gould, R. L. (1992). Adult development and brief computer-assisted therapy in mental health and managed care. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 347-358). Washington, DC: American Psychiatric Press.

This chapter presents a model of adult development based on Erickson’s theory that develop-ment, developmental blocks, and repair of previous developmental blocks occur at all ages. This paradigm of adult development lends itself well to short-term therapy, i.e., the goal being to find and resolve the current developmental block that is interfering with healthy function-ing. The author proposes the therapeutic learning program, which is a computer-assisted brief therapy program written for patients to work through themselves. The program consists of 10 interactive, sequential computer sessions. The patient also works with a therapist at the end of each session. This chapter describes each of the goals and objectives of the 10 steps, describes the advantages of such a program, and reviews an outcome study of the first 2,000 patients using this method.
Keywords: models, providers, psychotherapy

227. Hoyt, M. F., & Austad, C. S. (1992). Psychotherapy in a staff model health maintenance organization: Providing and assuring quality care in the future. Psychotherapy, 29, 119-129.

This article describes "good" therapy in an HMO setting. The essential characteristics of such therapy include crisis intervention; clear definition of patient and therapist roles; flexible and creative use of time; interdisciplinary collaboration; use of multiple treatment models; intermit-tent rather than long-term care; and utilization review. The authors recommend the use of groups and family systems approaches, as well as growth-oriented rather than cure-oriented approaches. They also review research evidence demonstrating the effectiveness of short-term therapy and outline strategies to ensure that quality of care and accountability are maintained.
Keywords: HMOs, providers, psychotherapy

228. Jellinek, M. S., & Nurcombe, B. (1993). Two wrongs don’t make a right: Managed care, mental health, and the marketplace. Journal of the American Medical Association, 270, 1737-1739.

In this commentary, the authors describe the evolution of the mental health delivery system from primarily "unleashed market forces" to "unopposed incentives to cut services." The authors argue that just as there were few countervailing forces against overutilization and misuse of mental health services in the 1980’s, there is currently little to check systematic profiteering from underutilization of services. They discuss the implications of the decreasing professional autonomy for psychiatrists and suggest what individuals and organizations can do to pursue specific political objectives. The article describes implications for primary care clinicians and why managed care represents both a threat and an opportunity.
Keyword: providers

229. Lane, N. E. (1994). Managed care and providers: You’re in business! In S. A. Shueman, W. G. Troy, & S. L. Mayhugh (Eds.), Managed behavioral health care: An industry perspective (pp. 65-75). Springfield, IL: Charles C. Thomas.

This chapter explores issues in managed behavioral health care from the perspective of the providers. The author directs her discussion to the mental health provider who may be feeling disillusioned with the changes in the field during the past decade. She describes concrete ways that providers can cope with these changes, such as how to view behavioral health services as a commodity to be bought, sold, marketed, and negotiated. Finally, she suggests ways that providers can approach managed care organizations about participation in their programs, and how to negotiate with these companies.
Keyword: providers

230. Olsen, D. P., Rickles, J., & Travlik, K. (1995). A treatment-team model of managed mental health care. Psychiatric Services, 46(3), 252-256.

This article examines the treatment-team model of managed care for mental health patients. This model includes an in-person assessment by a clinician who acts as the managed care agent, immediate accessibility of this clinician, referral services with a broad range of intensity, and participation of the managed care clinician on the treatment team. The advantages of this approach include an increased ability to provide patients with individualized services, and a more organized system of care management. Limitations of the model include difficulty in decision-making due to the presence of team decisions, and the potential for overuse of emergency care by primary care physicians.
Keywords: models, providers

231. Patterson, D. Y., & Sharfstein, S. S. (1992). The future of mental health care. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 335-346). Washington, DC: American Psychiatric Press.

In this chapter, the authors speculate on what the future of mental health care will hold as we move towards the 21st century. They review some of the critical historical turning points in mental health policy and briefly discuss current trends. These include the growing role of employers, perceived inadequacy of HMOs, widespread concern with the rapid rise of mental health and substance abuse costs, and concurrent decline in Federal and State direct oversight for public mental health care. They speculate that managed care will continue to grow in importance, that there will be a clearer definition of private versus public responsibility for health care, a clearer delineation of responsibilities between medical and nonmedical mental health care professionals, growing involvement of employers in health care, and increasing number of training programs to prepare clinicians for the 21st century.
Keywords: providers, trends

232. Resnick, R. J., Bottinelli, R. W., Puder-York, M., Harris, B., & O’Keefe, B. E. (1994). Basic issues in managed mental health services. In R. L. Lowman & R. J. Resnick (Eds.), The mental health professional’s guide to managed care (pp. 41-62). Washington, DC: American Psychological Association.

The chapter compares and contrasts the four most prevalent managed care systems: health maintenance organizations, preferred provider organizations, employee assistance programs, and competitive medical plans. The authors delineate the ways in which psychologists par-ticipate in these systemsÑas owners, shareholders, independent providers, and employees. Finally, the article examines the various professional relationship and practice issues that affect providers who work in managed care settings. The authors conclude that mental health profes-sionals in today’s practice environment need to be aware of the clinical and financial implica-tions of managed care systems so that they participate effectively and influence their design.
Keywords: overviews, providers

233. Richardson, L. M., & Austad, C. S. (1991). Realities of mental health practice in managed-care settings. Professional Psychology Research and Practice, 22, 52-59.

This article describes aspects of the managed care system that are of concern to psychologists. Topics discussed include mental health benefits under HMOs, the advantages and disadvan-tages of employment as staff or contractors, financial considerations in providing services in fee-for-service arenas, prospective payment and capitation plans, and potential barriers to treatment. The authors also review practice issues. Psychologists working in HMOs continue to prefer long-term psychodynamic approaches; however, efforts are underway to help these practitioners develop skills in providing short-term therapy. The authors argue that psycholo-gists in HMOs must address challenges such as reducing inpatient use, providing care for chronically ill and noncompliant clients, and interacting effectively in an interdisciplinary team. The pros and cons of providing service in a managed care system are outlined, as well as criteria clinicians can use in working in such systems.
Keywords: overviews, providers

234. Richardson, L. M., & Austad, C. S. (1994). Realities of mental health practice in managed-care settings. In R. L. Lowman & R. J. Resnick (Eds.), The mental health professional’s guide to managed care (pp. 151-168). Washington, DC: American Psychological Association.

See Richardson and Austad, 1991 (reference number 233) for annotation.

235. Root, L. S. (1991). Cost controls on mental health services: Context and the role of the professional. Employee Assistance Quarterly, 7(2), 1-13.

Cost control is a key concern for employers; employee benefits represent 37.6 percent of U.S. payroll costs. To address rising costs, employers offer health insurance through HMOs and preferred provider organizations that is less expensive than fee-for-service plans. The author describes three cost-containment strategies: exclusions and limits on coverage, managed care carve-outs, and employee assistance programs as case managers, and explains how these strategies are aimed at controlling behavior, use, and price. The author examines the context of cost-control efforts in both mental health and substance abuse services. He argues that mental health practitioners must be proactive and take initiative in creating an approach that manages the care of clients, not simply limits the cost of the care.
Keywords: costs, providers

236. Sabin, J. E. (1991). Clinical skills for the 1990s: Six lessons from HMO practice. Hospital and Community Psychiatry, 42, 605-608.

HMO clinical practice currently embodies many of the features that are being required of managed mental health care providers. These include attention to cost containment, identifi-cation of outcomes, practice audits and treatment guidelines. This author argues that identify-ing the skills required for clinical effectiveness and professional satisfaction in the HMO can be extremely valuable for all clinicians working in a managed care environment. He identifies six crucial skills that can help clinicians become more effective, and uses brief case examples to illustrate how these skills may be useful in managed-care settings.
Keywords: HMOs, providers

237. Sabin, J. E., & Borus, J. F. (1992). Mental health teaching and research in managed care. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 185-199). Washington, DC: American Psychiatric Press.

In this chapter, the authors argue that the accelerating shift from fee-for-service to managed care has created a need for a new set of training skills for clinicians to practice effectively. This chapter delineates six new skills that managed care clinicians should possess. Several examples of teaching programs designed to train mental health practitioners in skills appro-priate for practicing in a managed care environment are presented. In a separate section, the benefits and problems of conducting research in HMOs are discussed. The authors conclude that both academic medical centers and HMOs will gain substantially by fostering meaningful collaboration in training and research.
Keywords: providers, training

238. Sargent, S. C. (1992). Contracting and managed care payment options. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 53-67). Washington, DC: American Psychiatric Press.

The author of this chapter argues that mental health providers in the 1990’s must be able to design payment options that will work for them rather than respond to potentially inappro-priate managed care offers. This chapter offers a template for mental health providers to use when approaching and evaluating managed care opportunities. Six steps for managed care contracting are discussed in detail: preparation, proposal, negotiation, contract, implementa-tion, and evaluation/renegotiation. The author recommends that a provider have a template such as this one to help assess whether any given managed care plan will meet the needs of patients and their families.
Keywords: contracting, providers, technical assistance

239. Scheffler, R., & Ivey, S. L. (1998). Mental health staffing in managed care organizations: A case study. Psychiatric Services, 49, 1303-1308.

Temporal changes in staffing numbers and ratios within health maintenance organizations (HMOs) offer us a valuable tool for estimating the future composition of the health care work-force as the trend toward managed care organizations continues. This article examines such staffing configurations of mental health providers through case studies of two staff-model HMOs. In an effort to address the move of many HMOs to contracting out mental health services to specialized behavioral health organizations, the authors compare staffing ratios of these HMOs with a 1-year average from a managed behavioral health carve-out organization in the same State. Results indicate a decline in total number of patient care physicians regard-less of enrollment changes, similar ratios of general psychiatrists per 100,000 members between the two HMOs that were about half the State’s average, and a higher percentage of doctoral-level psychologists in the carve-out plan. The results highlight a need for future research focused on outcome measurement, the possibility of improvements in service delivery and quality through collaboration among provider types, and the effects of substituting non-specialist physicians for behavioral health services.
Keywords: carve-outs, HMOs, managed behavioral health care organizations, providers, staffing

240. Schreter, R. K. (1993). Ten trends in managed care and their impact on the biopsychosocial model. Hospital and Community Psychiatry, 44, 325-327.

In this article, the author expresses concerns about the impact of managed care on the bio-psychosocial model of diagnosis and treatment. He identifies 10 trends in managed care and examines their impact on clinicians and their clients. He argues that managed care in its present form is being transformed as mental health services are increasingly being carved out, and provider networks are becoming the norm.
Keywords: providers, trends

241. Schreter, R. K., Sharfstein, S. S., & Schreter, C. A. (Eds.). (1994). Allies and adversaries: The impact of managed care on mental health services (1st ed.). Washington, DC: American Psychiatric Press.

This edited volume is a collection of essays written by clinicians and mental health executives. The book revolves around paired essays (one representing the managed care view, the other the clinical view). In a section on clinical services, inpatient services, intermediate level of care, outpatient care, child and adolescent services, and drugs and alcohol are addressed. The same format is used to show the two perspectives regarding the role of providers, including the psychiatrist, psychologist, and social worker. Ethical issues under managed care, quality-of- care guidelines, and practice guidelines are also addressed. Essayists were asked to respond to two questions: What do you believe are the major problems with managed mental health care? What would you do to improve the situation? Many of the chapters are written in an informal, personal style with liberal use of anecdotes and case studies. The editors wrote the final chapter, entitled "How Adversaries Can Become Allies," in which they outline the areas of both conflict and agreement between managed care executives and clinicians and reiterate the need for dialogue between the two groups.
Keyword: providers

242. Schuster, J. (1991). Ensuring highest-quality care for the cost: Coping strategies for mental health providers. Hospital and Community Psychiatry, 42, 774-776.

Frustrated with mixed reviews regarding the ability of methods such as utilization review, diagnosis-related groups (DRGs), and HMOs to control health care costs, the Federal Government is now exploring other avenues to achieve cost control. These include increased attention to outcome studies, renewed interest in a national health care system, and the enact-ment of the Medicare Volume Performance Standard. Psychiatry has followed a different path with regard to cost control; for example, most psychiatric services have not been subject to DRG limitations. This author describes current cost-containment methods in mental health care and concludes that mental health providers be proactive in exploring cost-containment methods that provide the highest quality for the cost.
Keywords: costs, providers

243. Sederer, L. I., & St. Clair, R. L. (1989). Managed health care and the Massachusetts experience. American Journal of Psychiatry, 146, 1142-1148.

Managed behavioral health care represents both danger and opportunity for psychiatry. The authors describe some of the reasons for the rapid growth of managed care and the clinical, economic, ethical, and practical implications. They then discuss the ways in which psychia-trists have organized to counterbalance the trend. The authors describe the efforts of the Task Force on Managed Care of the Massachusetts Psychiatric Society to ensure that psychiatrists continue to play a major role in determining the destiny of psychiatric care. The task force chose to focus on three areas: developing criteria for minimal standards of care; certification and monitoring of utilization review organizations; and maintaining a second opinion service as a back-up for when a psychiatrist or patient disagrees with a managed care organization.
Keywords: providers, standards of care, utilization management

244. Sederer, L. I. (1994). Managed mental health care and professional compensation. Behavioral Sciences and the Law, 12, 367-378.

In this article, the author examines physicians’ organizational relationship to new managed systems of care as well as physician compensation within these systems. The paper presents three models of professional compensation: profit maximization, target income, and patient agency. The author then describes five different types of physician organizations, entities integrating physicians with health care systems. From these foundations, the author discusses the impact of managed mental health care on physician compensation and incentives, con-cluding that fully integrated, physician-hospital organizations with target income compensa-tion arrangements are the most successful for both physicians and organized systems of care. The paper includes a discussion of the dilemmas and challenges in bringing together managed care, organized networks of care, and professional compensation.
Keywords: economics, models, providers

245. Snibbe, J. R., Radcliffe, T., Weisberger, C., Richards, M, & Kelly, J. (1989). Burnout among primary care physicians and mental health professionals in a managed health care setting. Psychological Reports, 65, 775-780.

The authors administered the Maslach Burnout Inventory to primary care physicians and psy-chiatric staff (psychiatrists, psychologists and social workers) of a large health maintenance organization (HMO). They found that for all providers except psychologists, their HMO sample scored significantly higher on all subscales than the Maslach normative population of physicians and mental health professionals. Several interprofessional differences also emerged. For example, internists scored significantly lower on emotional exhaustion than did psychia-trists; however, psychiatrists scored higher on depersonalization than either family practition-ers or internists. The authors discuss implications of these findings for HMOs that include job rotation, mentoring systems, and workshops to help health care professionals recognize and cope with burnout.
Keywords: HMOs, providers

246. Sturm, R., Meredith, L. S., & Wells, K. B. (1996). Provider choice and continuity for the treatment of depression. Medical Care, 34(7), 723-734.

This article examines the effects that the changing payment system in mental health care has had on characteristics of the patient-provider relationship such as a choice of specialist versus generalist, and the duration of the relationship. The authors compare provider selection among depressed patients in prepaid and traditional fee-for-service (FFS) plans. Data from the Medical Outcomes Study are analyzed among three competing systems of care in urban areas across the country. The results of the patient survey administered by the authors finds that FFS patients were more likely than those in prepaid health plans to consider a psychiatrist to be their main source of care. FFS individuals were also found to have a higher probability of provider conti-nuity over time than those in prepaid health plans. This study may be useful in future policy analysis on issues of patient-provider relationships as well as the quality of care being offered in the managed behavioral health care market.
Keywords: depression, evaluation, providers

247. Thompson, J. W., Smith, J., Burns, B. J., & Berg, R. (1991). How mental health providers see managed care. Journal of Mental Health Administration, 18, 284-291.

This paper reports the findings from a 1989 study using focus groups to explore mental health practitioners’ attitudes regarding managed care. The 23 participants (psychologists and psychi-atrists) were ether contractors with managed care firms or on an "approved" list of providers. Although there were differences of opinion on a number of points, the general consensus of the groups was that managed care has adversely affected quality of care as well as their own practice. Participants believed that limits on the number of sessions and inpatient stays inter-fered with effective treatment. They identified barriers to engaging clients such as inappropri-ate intake assessments by untrained case managers and the subjective use of "standardized" criteria. The participants called for peer review, greater collaboration between providers and managed care firms, more stability in benefits and standards, and more autonomy in decision-making.
Keyword: providers

248. Van Gelder, D. W. (1992). Surviving in an era of managed care: Lessons from Colorado. Hospital and Community Psychiatry, 43, 1145-1147.

This paper discusses how managed care has affected nonprofit psychiatric facilities in Colorado, where more than half of the State’s population is covered by managed care plans. The author describes the strategies one facility has used to function effectively in an era of cost containment. Because of a decrease in length of stay, the facility needs more patients to maintain a full census. To achieve this, the facility has trained staff in brief treatment and implemented a marketing campaign to generate referrals. The author suggests a number of approaches to prevent declines in employee morale should layoffs become necessary. These include making the facility mission clear to employees and giving them a say in decisions about cutbacks.
Keyword: providers

249. Wagman, J. B., & Schiff, J. (1990). Managed mental health care for employees: Roles for social workers. Occupational Social Work Today, 53-65.

Case management is a major strategy for controlling skyrocketing mental health costs. The authors identify the causes of the problem of high costs, how case management is being used to address this problem, and the role of social workers in case management and employee assistance programs. Social workers possess skills that are useful in assessment and referral, as well as in review and monitoring of treatment. Managed mental health care has provided many opportunities for clinicians who are competent in both direct practice and administrative skills. The authors argue that as the field of managed mental health care grows, social work education will need to address the emerging roles that it presents for social workers.
Keywords: case management, providers

250. Whittington, H. G. (1992). Managed mental health: Clinical myths and imperatives. In S. Feldman (Ed.), Managed mental health services (1st ed., pp. 223-244). Springfield, IL: Charles C. Thomas.

This chapter argues that the clinical, social, and economic imperatives in favor of a managed mental health approach are compelling. The author identifies and refutes a number of myths about managed mental health care. These include beliefs such as that controlling physician behavior is amenable to simple economic incentives; that mental health care is unmanageable; that adverse selection will occur if good mental health benefits are offered; that patients as a rule overutilize psychotherapy, and that managed care results in poorer service outcomes. The author argues that the skepticism with which managed mental health and substance abuse services are viewed by the general public and payors is largely due to ignorance about the clinical and economic realities of such services; and that managed mental health repre-sents an opportunity to improve both clinical outcomes and economic efficiency.
Keywords: economics, providers

251. Zakheim, M. H., Leifer, J. C., & Schwartz, R. A. (1998). A guide for providers of mental health and addictive disorder services in managed care contracting: Vol. 9. Managed care technical assistance series. Rockville, MD: Substance Abuse and Mental Health Services Administration.

As more and more health care providers are contracting with managed care organizations, it has become increasingly important for providers to understand the structure and organiza-tion of these contracts before they begin to negotiate. The purpose of this guide is to assist providers of publicly funded substance abuse and mental health services as they enter into contracts with managed care organizations. In particular, the discussion centers around the wording of these contracts, with a focus on identifying commonly found weaknesses in the provisions and recommending alternatives. The guide is composed of five sections: Funda-mentals of Managed Care Contracting, Scope of Services, Financial Issues, Eligibility and Enrollment, and Dispute Resolution and Conditions of Termination. Each chapter presents a discussion of a specific type of contract provision as exemplified by relevant excerpts from actual contracts followed by critiques and recommendations.
Keywords: contracting, providers, public sector, substance abuse, technical assistance

252. Zimet, C. N. (1989). The mental health care revolution: Will psychology survive? American Psychologist, 44, 703-708.

The author argues that psychologists should help shape the managed care system. The key tasks for psychologists are to provide high-quality care and to assert their role in providing that care. The article provides an overview of managed care as a cost-containment approach. Although psychiatric hospitals have been exempted from cost containment, it is only a matter of time before these facilities are reimbursed prospectively and treatments are paid at a fixed rate. Reimbursement limits will have important implications for psychologists. The article also describes the ways in which psychologists can play a role in assuring quality assurance, developing reimbursement guidelines, and in advocating for the use of mental health services as a way of reducing medical costs.
Keyword: providers

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This page was last reviewed by Dr Greg Mulhauser, Thursday, 14 October 2021.