Given that passion, opinion, opportunism and inertia have shaped much of managed care's evolution, there is an increasing need for the systematic gathering and rational application of facts. Outcome evaluations and insights into what facilitates and what impedes efficient and effective care are now avidly sought, not only for improving care delivery and treatment effectiveness but also for regulatory functions and commercial promotion.
Having become increasingly involved in academic as well as clinical aspects of managed care, the department of psychiatry at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School, with support from an unrestricted educational grant from Pfizer Inc., is establishing one of the first managed care behavioral health services research fellowships.
Additionally, we have been evaluating aspects of managed care using a set of data accumulated by the telephone access center. The center serves a behavioral health care provider network sponsored by the department of psychiatry. Although created for administrative purposes, the access center's database provides a novel opportunity to study communication and decision-making in psychiatry and managed care operations.
For our first investigation, we selected one sharply defined aspect of therapeutic
decision-making and reported some of our findings at the 1998 American Psychiatric Association Annual Meeting in Toronto (Ciccone et al., 1998). Surprisingly, few data-driven analyses of managed care decision-making were presented at the meeting. In contrast to psychiatry, other mental health disciplines are more actively investigating various aspects of managed care.
Our new research poster focused on how well the access center, using operational criteria, differentiates between callers considered appropriate to be seen first by psychiatrists from those considered appropriate to be seen first by social workers or psychologists. We found a high rate of agreement between the treatment and interdisciplinary referral decisions made by the clinicians who eventually treated the patients and the access center workers' choice of clinician disciplines for the patients' initial appointments (Table).
Information FlowPhysicians commonly grumble that current implementations of the managed care paradigm severely interfere with their relationship to patients. Doctors also express misgivings about whether the electronic interfaces envisioned for telemedicine can convey essential nonverbal material. Many believe that critical information is lost if a patient is not seen face-to-face.
Because behavioral health care is considered especially vulnerable to factors that impinge on the doctor-patient relationship, it should be a good arena for tracking information that contributes to treatment outcome. Specifically, adverse situations such as having to discuss one's psychiatric problems over the phone with a stranger in order to get help should limit the transmission of crucial clinical data in a measurable way.
Our access center included disadvantageous features of both managed care and telepsychiatry, creating a severe test bed for examining whether useful clinical communication could occur over the telephone or in a managed care setting. Although the supposed disadvantages of telephone interviews and impersonal managed care transactions seem clear intuitively, the actual impact of such conditions on clinical communication has not been quantified.
The provider group associated with our department of psychiatry receives fee-for-service under a managed care contract that covers some 130,000 lives for ambulatory services. The multidisciplinary practice sites in the network are located in five counties. As far as we know, this is the largest such operation under academic auspices. Families eligible for services have subscribed through an employer, and most families live in suburban communities, creating a relatively homogeneous population.
The usual entry point for our care system is a centralized telephone access center operated by University Behavioral Healthcare, which is administratively distinct from the academic department of psychiatry. This access center is staffed by professionally trained, clinically experienced care managers (CMs). Their mission is to arrange an appointment for each caller with a network clinician in as timely, convenient and clinically appropriate manner as possible. To do so requires effective communication to ascertain the problems for which the caller wants help.
In a large room in Piscataway, N.J., each CM sits in a sound-isolated carrel equipped with a networked computer. The computer presents checklists and text fields to help the CM conduct a semi-structured interview. It then lists intake appointments that are available at locations convenient for the caller. On the basis of checklist data, the computer shows which available clinicians have special clinical proficiencies that may be required for treating the caller's issue or disorder.
