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Access Issues in Behavioral Health Care
http://www.medscape.com/
from Drug
Benefit Trends®
Posted 10/28/2002
Jay M. Pomerantz, MD
The behavioral health marketplace is complex and confusing.
Initial access to care is usually through a central telephone
intake and certification process. Almost all MCOs use this
method, especially the national behavioral health carveouts.
The number to call is listed on the back of the subscriber's
insurance card. The process seems simple enough, but let's
look behind the scenes to see how things really work -- or
don't work.
Patients usually ignore the fine print on the back of their
insurance cards. They assume that their medical insurance
operates the same way for behavioral health as it does for
other specialties of medicine. After all, they have been
referred for behavioral health services by a primary care
physician and have been given the names of psychiatrists,
psychologists, or psychiatric social workers to call. So the
patients call these practitioners and wait for a return call,
which is usually late in coming because most mental health
professionals operate without secretaries. When the mental
health professional finally returns the call, the conversation
is primarily about which behavioral carveout network the
patient's insurer has subcontracted with, rather than the
patient's symptoms.
In most fields of medicine, the majority of practitioners
participate in most networks; however, this is not the case in
behavioral health care. Carveouts traditionally have kept
their networks small to better control utilization, and many
practitioners have either not joined or quit networks, which
may underpay or hassle them. Moreover, many companies keep
their network list private. In any event, the patient
eventually must call the insurance company or carveout network
to explain the need for services and to obtain the names of
local, in-network behavioral health providers.
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So the patient starts over again, often being greeted with
the bad news that the practitioners in that particular network
are all too busy to see new patients. When a therapist is
finally obtained, often he or she is a psychologist or social
worker who may need the assistance of a psychiatrist for
medication consultation or if the case is complex. Once more,
the patient must repeat the process of telephoning the MCO and
mental health practitioners but is often greeted with a new
complication. Even if the patient finds a psychiatrist in the
network, that practitioner may not be willing to work with the
patient's current therapist. (Psychiatrists fear malpractice
lawsuits as a result of sharing treatment with unknown or
questionably competent psychotherapists.) For the patient or
anyone else trying to set up treatment covered by insurance,
it is a mix-and-match scenario with many false starts and dead
ends.
In a recent article, William Goldman, MD, the senior vice
president of behavioral health services at United Behavioral
Health (part of United Health Care), provides the industry's
point of view. He complains, in particular, about
psychiatrists. Even when psychiatrists join networks, they may
choose to be unavailable to care for network patients.[1]
Such a phenomenon, if present, would further complicate
patients' access to psychiatric care. Before one could even
suggest a remedy, however, one needs to explore the issue. Two
questions jump out: why would a provider join a behavioral
health network, yet not be open to its patients, and why would
behavioral health networks tolerate such practitioners on
their roles?
The answer to the first question is that most established
practitioners have their own referral system, which primarily
consists of self-referred former patients and their families
and friends, primary care physicians, and other mental health
professionals. Most of the patients being referred have
insurance, and the behavioral health practitioner being on
insurance panels makes treating these persons possible.
Furthermore, one's long-term care patients often change
insurance companies, sometimes yearly, as employers search out
the low bidder or best value. In any event, behavioral health
specialists find it convenient to be listed on several panels.
There is little downside risk. If an insurer or behavioral
health carveout does not pay well or provide correct paperwork
or presents other major obstacles (eg, difficulty in
hospitalizing high-risk patients), one merely turns down any
new patients from that network, especially those referred by
the central telephone intake personnel.
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Although the insurance and carveout folks know what's going
on, they have reasons for tolerating it. For one thing, they
are constantly under pressure from purchasers and oversight
bodies (eg, the National Committee for Quality Assurance) to
show a large and diverse network, especially one including
many psychiatrists -- the behavioral health specialty best
able to prescribe medication and manage the care of
difficult-to-treat and high-risk patients. Second, from a
financial standpoint, the behavioral health budget benefits to
the degree that potential patients never successfully access
treatment that insurance covers. Insurance companies profit
when patients resort to any provider who has an opening, even
if that provider is not covered by the patient's insurance.
Other patients return to their primary care physician with
their tale of frustration and are treated with medication
only, which may or may not benefit the insurance company (but
does benefit carveouts). Still others give up on treatment
altogether and do the best they can without it. This self-help
may not be good enough, given the daily reports in newspapers
of suicides, domestic violence, workplace shootings, and a
rising prison population. While thesecosts to society are
real, they are not easily measured or directly attributable to
behavioral health access problems.
The quickest way to find out whether a behavioral insurance
network is real or illusory is to measure a network's treated
prevalence rate per year (usually termed "penetration
rate"). Excellent behavioral health networks have
penetration rates of 8% to 10% or greater, whereas average
ones will have a rate between 5% and 6%. The latter figure is
based not only on the experience of managed health plans but
also epidemiologic and health services research on the rates
of specialty mental health service use in the United States,
which runs 5.6% to 5.9% per year.[2, 3] One can be
reasonably sure something is amiss when a network reports
penetration rates for behavioral health specialty treatment
below those figures. Cuffel and Regier,[4] as well
as Weissman and colleagues,[5] have found a direct
and linear association between the spending in a managed
behavioral health organization and the penetration rate. As
usual, you get what you pay for -- behavioral health access is
no exception.
Another way to determine the extent of access problems may
be to collect instances of consumer complaints about access to
both the managed health plan and any oversight agencies.
Unlike penetration rates, these reports are anecdotal and may
represent unreasonable consumer demands rather than system
impediments to medically necessary behavioral health care. It
is also difficult in many instances to separate legitimate
manpower shortages of certain specialties in particular areas
(eg, child psychiatrists in rural areas) from administrative
or funding problems.
All that being said, some method of measuring the
percentage of the insured population who end up paying
out-of-pocket for ostensibly covered behavioral health
treatment would be another way of determining and confronting
access problems. Something is clearly amiss with insurance
arrangements that persons pay for but "choose" not
to use. For example, in an article studying predictors of
outpatient mental health utilization by primary care patients,
Simon and colleagues[6] report that among
interviewed participants, 5.1% used mental health services
within their HMO (mean, 2.92 visits) and 8.9% purchased
outside mental health services (mean, 8.86 visits). Is that an
access problem?
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Dr Pomerantz practices
psychiatry in Longmeadow, Mass, and is an assistant
clinical professor of psychiatry at Harvard Medical
School in Boston.
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