Managed Care Experiments With New Procedures

With psychiatrists’ discontent and frustration over the amount of control managed care exerts on medical decision making as strong as ever, some firms are responding by trying different operational procedures and services that they hope will be less intrusive while also saving time and reducing costs.

Lawrence Lurie, M.D., of San Francisco and chair of the APA Committee on Managed Care, said in an interview: “The trend is good. They are trying to make it easier—not because they like psychiatrists, but because it will save them money and may be more efficient.”

Telephone authorization is one such innovation being investigated by United Behavioral Health (UBH), the nation’s third largest mental health carveout with some 20 million enrollees. The goal is to replace the submission of written treatment plans with a telephone authorization system. The company tested the concept last year in Pennsylvania.

Here is how it works: Say, UBH agrees to pay a psychiatrist for 10 psychiatric sessions, but the psychiatrist believes that more sessions are necessary. Instead of having to fill out a new treatment plan for the patient and mail it to UBH to get the go-ahead on more sessions, the psychiatrist calls the company at a toll-free number, listens to preprogrammed questions about the patient, and provides the answers by pressing a corresponding number on the phone keypad. The answers are then fed into a computer, and after two to four minutes, the system either authorizes extra sessions or leads to a case manager’s coming on the phone to discuss the complexities of the case and arrive at a decision.

After UBH was through testing this phone-authorization system in Pennsylvania, it sent a survey to psychiatrists, psychologists, and social workers who had participated in the study to learn their reactions to the system. David Nace, M.D., corporate medical director of UBH in San Francisco, and his colleagues there weren’t sure how providers would react. “We were flabbergasted by the tremendously high percentage of people who were very happy with it,” he told Psychiatric News. As a result, UBH is going to roll out the phone-authorization system this year to a number of its major national accounts.

Lurie, however, has some reservations about the innovation. As he put it, “It takes me 15 minutes to fill out an authorization form. So, the question is, will a telephone system or computer system on my telephone take considerably less time? How long will the keypad process take? If I call, will the line be busy?”

ValueOptions is exploring the feasibility of letting psychiatrists obtain authorization for treatment online.

“In a couple of places all the authorizations are done online, so psychiatrists don’t even talk to anyone,” said Don Fowls, M.D., a Norfolk, Va., psychiatrist and the executive vice president and national medical director of the second biggest mental health carveout in the United States, ValueOptions. “And it is done very quickly—it takes about 30 seconds. Yet it is done in the context of clinical criteria and guidelines, so that quality issues are being addressed. It is not just ‘register and get paid.’”

Eliminating authorizations altogether is being considered by Alliance Behavioral Care in Ohio. The replacement process would involve tracking the treatment behaviors of network psychiatrists over the long haul and continuing to do business with those psychiatrists who engage in more “economical” treatment behaviors. This news comes from Allen Daniels, Ed.D., CEO of Alliance Behavioral Care in Ohio and chair of the American Managed Behavioral Healthcare Association in Washington, D.C.

Ohio also has been a testing ground for UBH on doing away with having psychiatrists obtain authorization for sessions and instead requiring employees to obtain it. Employees of the state of Ohio are among UBH's members, and UBH decided to test drive the idea on them. Whenever an employee wanted to see a psychiatrist, UBH granted 10 sessions with a psychiatrist immediately unless the employee was in psychological crisis, and in that case, UBH sent the person to a hospital emergency room.

This procedure, UBH found, did not cost it any more in psychiatric payments than when it had made psychiatrists obtain the authorizations. As a result, Nace said, UBH is phasing it in to more of its members.

Changes in the treatment realm are also under way. PacifiCare Behavioral Health has developed a system to track the progress of its members in psychotherapy and to alert psychiatrists whenever patients do not seem to be progressing or appear to be getting sicker.

The system, known as ALERT, is based on the Life Status Questionnaire that two Brigham Young University psychologists developed. The questionnaire is designed to detect small changes in levels of well-being that a patient in psychiatric treatment might experience from week to week and that especially might indicate suicidal risk or problems with chemical dependency or alcohol.

Here is how it works. When a member calls PacifiCare Behavioral Health to locate a network psychiatrist, he or she completes the questionnaire and sends it to the company. When the member visits a network psychiatrist, he or she again fills out the questionnaire, and the psychiatrist faxes it to the company. This process repeats itself over subsequent psychiatric visits. Results from the questionnaires completed initially and from the psychiatric visits are then compared. If the member appears to be becoming more psychologically distressed instead of less so, PacifiCare Behavioral Health alerts the psychiatrist.

But does ALERT really work? It was first introduced in 1999 in California. Since then, PacifiCare Behavioral Health has studied its impact on some 7,300 members, leading to several important discoveries, according to PacifiCare Behavioral Health’s corporate clinical director, Edward Jones, Ph.D., at a January press conference.

For one, he said, ALERT is not only able to measure changes in members’ psychological well-being during treatment, but also to predict what members’ progress in treatment should be, because PacifiCare Behavioral Health has a database showing how similar individuals in treatment have progressed. For another, he said, ALERT is valuable for targeting persons who are at high risk of suicide. On the basis of these study results, PacifiCare Behavioral Health has rolled out ALERT to members in all states where it does business.

“Of course, success will depend on collaboration with our providers,” Jones admitted, “and whether they will collaborate will depend on whether we put useful clinical information in their hands.”

APA’s Lurie, however, has some deep concerns about this particular program. “Obviously it doesn’t hurt to have additional written confirmation about a patient’s condition,” he said. “But in some cases having a patient fill out a form, sending it in, and getting it back may not be the clinically appropriate thing to do. A psychiatrist should certainly know if a patient is suicidal when he comes into the office. To learn it from a form that has been sent back to you feels very uncomfortable. I would also like to see some examples of what psychiatrists have learned from such forms that they didn’t know before.”

Online Changes

Some reimbursement changes are also looming large. PacifiCare Behavioral Health has just launched a pilot study that allows network psychiatrists to submit claims via the Internet, according to Jerome Vaccaro, M.D., president and CEO of PacifiCare Behavioral Health in Van Nuys, Calif. “What we anticipate,” he said, “is that over the course of the next year we will roll it out to the entire network.”

Lurie raised these questions, however: “Will it be faster? Will it be more efficient? Will it actually result in fewer mistakes? That is one of the problems with claim payments—correcting such mistakes takes a huge amount of time. If it leads to fewer mistakes, that would be a real plus.”

MAMSI Health Plans has a Web site where psychiatrists can learn about the status of the claims they have filed.

Regarding claims payment via the Internet, Fowls said, “We at ValueOptions are definitely going to do this; we are committing our future to it.”

Reimbursement for online medication visits is also a possibility. “We are pilot testing this now in Arizona,” Fowls said.

Former APA President Harold Eist, M.D., said, however, that he found this tact “appalling” and accused MBHOs contemplating it of sacrificing proper patient care in order to “simplify payment procedures.” Lurie expressed similar concerns.

Marcio Pinheiro, M.D., of Sykesville, Md., is the creator of an APA caucus for psychiatrists treating patients covered by managed care. He hopes that these latest managed care changes “will give providers a stronger voice in dealing with these corporations.” Nonetheless, he remains skeptical “because their motivations are not the same as mine. I am motivated to treat people, and they are motivated to make money by not treating people.” ▪