While managed care is willing to pay more for inpatient services, outpatient services are still getting short shrift, according to Covall. "It's not the same dynamics. We're faced with a number of clinicians who are unwilling to take managed care business. There's a growing reluctance to take rates that are below what it costs to deliver services."
Ray agreed saying, "Many community-based providers may have turnover rates of as much as 20% to 30%, emphasizing the fact that most Americans who receive any form of behavioral health treatment receive it from their primary health care provider. Primary care physicians now account for 65% of all the psychotropic prescriptions that are written in this country. For the patient, that means there is a risk they will be poorly diagnosed or misdiagnosed."
"There is a trend toward increasing the use of primary care for the initial front lines," noted Robert I. Field, Ph.D., J.D. Field is the director of the Health Policy Program at the University of the Sciences in Philadelphia. "The idea is to encourage family practitioners and internists and pediatricians to screen for depression. A large percentage of patients who are on [selective serotonin reuptake inhibitors] are being treated by primary care physicians," he told PT, noting that last May the U.S. Preventive Services Task Force recommended routine screening of all patients for depression.
Eisdorfer called that effort "a move from carving out to carving in. They're trying to move mental health into the primary care arena by providing screening and evaluation tools to primary care providers. The [U.S. Department of Veterans Affairs] has done that very successfully, and the Robert Wood Johnson Foundation has been dealing with a version of this. The reason is there are very significant economics that pay out on the health care side: Early evaluation of depression and then management by a psychiatrist is quite cost effective."
Economics also drives another trend that Eisdorfer cited: "Targeted case management, that is to say, the notion of identifying those individuals who are most needy based on past experience and developing proactive programs to help them and try to ensure that they will be less likely to need hospitalization."
Consolidation is a major trend in behavioral health care not just among hospitals, where a substantial number of beds have been lost to closures and mergers in the last five years, but also among managed care companies. Many managed care companies are turning to in-house clinical staff to provide behavioral health care.
"We're seeing fewer mental health carveout companies," said Eisdorfer. "Instead, there's a lot of movement toward using staff in effort to reduce the costs. The larger companies like United Healthcare are basically staff operations, which raises the issue of whether you have full-time staff providers as opposed to community-based providers. The overall increase right now of managed health care means, arguably, in the end there will be fewer providers. But the companies may have pushed the trend too far in the direction of less well-trained providers, and there may be a need for more psychiatrists in mental health managed care."
If there is a move back to community-based care, however, the managed care industry may find that it has difficulty in finding clinicians to provide the services. "Some practitioners are saying they will not join a panel, they won't take HMO patients," Ray said. "They say they can charge 70 bucks cash-and-carry, take [credit cards] and not be worried about filing paperwork. More practitioners are going to that. And there are more niches opening up: Internet-based 'counseling' or boutique practitioners."