The practices of managed care systems, however, must be compared with those of unmanaged care settings, where there is much variability of quality. A survey of pediatricians in a single HMO by Halpern-Felsher and colleagues (2000), for example, found that preventive services were provided to adolescent patients at rates below the HMO's recommendations, yet above the rates measured in other practice settings. The authors found that improvement was needed in the areas of preventive care that contribute most to adolescent mortality, including depression and suicide assessment, for which, respectively, only 46% and 35% of practitioners screened.
Provider education offered by HMOs and PPOs aims to reduce treatment variations, cut costs and standardize quality. Materials sponsored by managed care companies, however, are not uniformly welcomed by providers. Educational lessons, packaged as practice enhancements and/or evidence-based practice guidelines, are seen by some clinicians as tools that attempt to restrict practice options and discourage independence and creativity.
In a randomized trial of the effects of guideline dissemination, Azocar et al. (2003) found that the dissemination efforts of a managed behavioral health care organization failed to improve the adherence of mental health care clinicians to practice guidelines. Sharar and colleagues (in press), furthermore, surveyed executives and managers at managed behavioral health care organizations and concluded that the guidelines they prepare may lack objectivity and be subject to political pressures that affect their development.
Limitations on specialty referrals, sessions and medications all threaten to curtail the ability of the psychiatrist to care for the suicidal patient. Indeed, many clinicians who treat adolescents and who participated in a service provider survey perceived that not all of their desired psychiatric services were offered within the network (Yanos et al., 2003). Van Voorhees et al. (2003), in a questionnaire sent to primary care physicians, reported that a higher level of managed care market penetration was associated with lower perceived access to mental health services. In a review of the Massachusetts Behavioral Health program, then in its seventh year, the program was deemed an overall success, but not without its shortcomings (Beinecke and Vore, 2002). Providers complained of limited access, especially to inpatient and community residential programs, and were also worried about alarmingly short hospital and residential stays. Furthermore, the report cited a lack of coordination among state agencies, as well as lower than expected levels of integrated care. The latter was seen as a result of low or no reimbursement for collateral contacts (Beinecke and Vore, 2002). Sadly, all three reports suggest that managed care influences providers' perceived access to mental health care specialty providers--clinicians who should be made especially accessible in addressing a suicidal patient's crisis.
Patients with especially acute and intense risk for suicidal behavior are sometimes most safely and effectively cared for in inpatient settings, so managed care restrictions on access to inpatient care is perceived by clinicians as a particular concern. Some treatment systems that treat large numbers of patients insured by managed care systems have developed alternative outpatient programs to meet the needs of suicidal patients. Harney (2001) provided guidelines for clinicians trying to provide such alternatives to hospitalization and reported that one of the benefits of the managed care revolution has been the development and expansion of good outpatient services for suicidal patients. The benefit of such programs may provide some explanation for the observation that a 56% reduction in mandated state transfers to a psychiatric hospital in Fulton County, Ga., was not accompanied by any increase in the suicide rate (Garlow et al., 2002).
Administrative paperwork, used to justify payments and continued treatment, is an important aspect of managed care systems that impacts clinicians' treatment of suicidal patients. The added workload allows less time to spend with patients and strains the clinicians' ability to care for high-need patients, especially those who are suicidal (Beinecke and Vore, 2002; Yanos et al., 2003). The additional time-consuming task of bargaining with utilization managers for resources and treatment authorization adds significant time to the providers' job, often requiring unreimbursed additional hours of work.
In light of the ubiquitous presence of managed care in our current health care environment, some recommendations can be made for clinicians treating suicidal patients.
First, clinicians assessing new patients must not curtail the suicide evaluation process, including history of present illness, examination of mental state, and pertinent past and family history (Maltsberger, 1988). While time pressures imposed by managed care may tempt the practitioners to hurry the evaluation process and cut corners, the compressed treatment periods imposed by HMOs make accurate diagnosis--especially of suicide risk, substance abuse or psychosis--even more critical. At follow-up visits, clinicians must remain ready to explore changes in safety or suicide risk if warranted by any changes in a patient's circumstances, behavior or mental status.