There are also options with which most mental-health consumers are unfamiliar, according to Jacqueline Fox, a Washington, D.C-based lawyer who deals strictly with health-insurance appeals. Almost half of Fox's clients are battling MBHOs. "Get the contract between your employer and the insurance company, not your member-benefits handbook," advises Fox. "The benefits booklet is just the first salvo in an ongoing battle." Fox also recommends managed-care ombudsman programs, available in states including Virginia, Maryland, Colorado, Florida and Connecticut.
Successful appeals can 'be mounted without legal action. When Ann O'Callahan's child suffered a second psychotic break in 1998, Blue Cross Blue Shield of Massachusetts refused to extend inpatient treatment beyond 37 days. O'Callahan spent four weeks researching her case with lawyers, doctors and advocacy groups. When she submitted an appeal rife with treatment plans and expected outcomes, the MBHO granted an additional four and a half months of inpatient care.
"In treating mental illness, the gap between what we know, thanks to scientific research, and what we do, because of managed care, is widening," declares O'Callahan. "I'm not the least bit unusual in that I love my child. But I might be unusual in that I was unwilling to take Blue Cross Blue Shield's 'no' for an answer."
DOES THE SYSTEM WORK?
Psychology Today sought perspective on managed care and mental illness from a provider, KEITH DIXON, Ph.D., president and CEO of CIGNA Behavioral Health, and from a consumer advocate, MICHAEL FAENZA, M.S.S.W., president and CEO of the National Mental Health Association (NMHA).
PT: What is managed behavioral hearth care?
Dixon: Managed behavioral health care is the private application of community mental health [concepts]. The principles underlying the Community Mental Health Centers Act of 1963 were stewardship, prevention, independence, teamwork and accountability. These may not seem revolutionary, but they are. Stewardship challenges the notion that caregivers are unbridled advocates for their individual patient. Teamwork challenges the archetype of the provider as working autonomously to cure disease. Managed behavioral health care is controversial, because community mental-health care was controversial.
Faenza: Managed care is just a set of strategies to contain costs. They can be used well, preserving resources, or poorly, reducing access and quality of care. Managed behavioral health care has taken over the private sector during the past 15 years and has more recently been impacting public sector programs.
Managed hearth care often gets bad press. Is it justified?
Dixon: Occasionally, it's deserved; most times not. I am stunned when I see managed-care companies characterized in the media as greedy insurance clerks overruling doctors and denying care in the interest of profit. At CIGNA Behavioral Health, anyone dealing directly with a clinical case is a licensed psychologist or clinical social worker reporting to a board-certified psychiatrist. Lots of medical errors occurred before managed care came onto the scene, and in mental health, lots of strange therapies got passed off to consumers.
Faenza: Some bad press is justified, some is not. The managed-care industry does get blamed for problems beyond its control. Public programs have always been grossly underfunded. There are many geographic areas lacking clinicians and treatment facilities--regardless of managed care. But there are many valid concerns about managed care that are justly receiving media coverage.
What about lawsuits against managed behavioral health-care companies?
Dixon: I've never understood why we go to court in the first place. Managed-care companies don't deny care; they sometimes deny payment for a level of care that is inappropriate to the patient's condition, is not a covered benefit or is a treatment that violates professional standards.
Faenza: The more prominent lawsuits include allegations of antitrust, of restricting prescribing practices and even misleading the public. The NMHA supports legislative efforts giving consumers the right to sue their health plans for poor health outcomes when treatment has been denied.
In what wags do consumers benefit from managed behavioral hearth care? And what are they Losing?
Dixon: Consumers benefit from preventive services in their Employee Assistance Program, one-stop shopping through databases on clinician availability and receiving professional guidance to a network clinician providing services that cost less than what the consumer would pay on his own.
Faenza: Managed care successfully redirected many people out of inpatient settings in the private sector. The range of treatment services also expanded as managed-care companies sought less expensive alternatives. However, as management of financial resources intensifies, people are losing their ability to readily access care.
What does the typical MBHO plan cover?
Dixon: Benefits cover the full continuum of care. When employers want to "buy down" [provide fewer] benefits, we try to discourage them from doing so. We promote flexible treatment benefits that cover hospital care, day treatment, partial day treatment, structured outpatient programs and individual psychotherapy.
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