While managed care generally has limited inpatient care and contained short-term costs for mental health and substance abuse services, significant questions remain about how these changes in health care delivery affect the quality of care patients receive.
Some answers are emerging in quality assessment and quality improvement studies described in a recently released government report, Parity in Financing Mental Health Services: Managed Care Effects on Cost, Access & Quality, prepared by the National Advisory Mental Health Council (NAMHC) and the National Institute of Mental Health (NIMH). (See also parity story in PT, November.)
Traditionally, quality of care has been assessed on three dimensions: the structure of the health care organization or system, the process of the delivery of health services, and the outcomes for the consumers of those services. Such outcomes might be clinical (e.g., symptoms, course or relapse), functional (e.g., social and occupational functioning, ability to participate in activities of daily living), and attitudinal (e.g., patient satisfaction).
Quality of care can be enhanced or diminished under managed care, according to the report.
"Case management, utilization review and implementation of standardized criteria may reduce services that are unnecessary, overly intensive, and neither goal-directed nor demonstrably effective," the report said. As an example, the report cited the study by Frank et al. (in press), which found that not only is adherence to professional consensus treatment guidelines enhanced in managed behavioral health carveout plans, but that adherence to such guidelines has a positive effect on patient outcomes (Katon et al., 1997).
However, in some cases, the introduction of managed care has limited access to mental health services, resulting in "decreased work performance, increased absenteeism and greater use of medical services."
A study at Yale (Rosenheck et al., unpublished data), for instance, examined the effects of managed care over time on employees of a large national corporation. The study compared three-year trends in the use and cost of specialty mental health and general mental health services as well as trends in employees' absenteeism and work performance. Use of specialty mental health services decreased by 41% in outpatient settings and 4% in inpatient settings during the study period, resulting in a 44% decrease in mental health care costs. But there were hidden costs.
"Compared with other employees, users of specialty mental health services showed significantly reduced work performance over time (down by 5.1%), increased absenteeism (sick leave up by 21.9%) and increased general health services costs (up by 36.6%). These trends offset any savings in mental health specialty costs and resulted in no net economic benefit or loss to the company," the report said. "These findings raise concerns that in the three-year shift to increased use of general health care services for mental health care, employees may have received less appropriate and less effective treatment, resulting in a decline in work function."
American College of Mental Health Administrators (1997), Santa Fe Summit Summary Report.
Frank RG, Berndt ER, Busche SH (in press), Price indexes for the treatment of depression. In: Measuring the Prices of Medical Treatments, Triplett J, ed. Washington, D.C.: Brookings Institute.
Goldman W (1997), Goal-Focused Treatment Planning and Outcomes. United Behavioral Health.
Goldman W, McCulloch J, Sturm R (1998), Cost and utilization of mental health services before and after managed care. Health Aff (Millwood) 17(2):40-52.
Kane RL, Barlett J, Potthoff S (1995), Building an empirically based outcomes information system for managed mental health care. Psychiatr Serv 46(5):459-461.
Kane R, Beyer Z, Potthoff S (1998), The future of outcomes monitoring in managed behavioral health care: report to NIMH from MCC Behavioral Health Care and University of Minnesota School of Public Health, Clinical Outcomes Research Center, Minneapolis, Minn.
Katon W, Von Korff M, Lin E et al. (1997), Population-based care of depression: effective disease management strategies to decrease prevalence. Gen Hosp Psychiatry 19(3):169-178.
Wells K (in press), the design of "Partners in Care": evaluating the cost-effectiveness of improving care for depression in primary care. Social Psychiatry and Psychiatric Epidemiology.