Popple5 c9[1]

CHAPTER 9
Mental Health:
Managed Care
The Policy-Based Profession
An Introduction to
Social Welfare Policy Analysis
for Social Workers
Fifth Edition
Philip R. Popple & Leslie Leighninger
Slides by Heather Kanenberg, University of Houston, Clear Lake

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Managed Care
• Primary method of providing health care
benefits today
• In 2008 over 65% of the Medicaid
beneficiaries are enrolled in some form of
managed care
• Managed Care Organizations have in recent
years become the primary providers and
administrators of mental health services in the
U.S.


Managed Care: The Problem
• Which Problem?
– The increasing cost of mental health care
– The need to improve the quality of care for those
with mental illnesses
– The need for corporations in the managed care
industry to increase their networks and to reach
new areas of society
• How do we determine which is the driving
force?

Mental Health Care
• Costs:
– Ten percent of the health care expenditures are on Mental
Health Care
– Untreated mental illness is estimated to cost $1923 billion
in lost earnings in the U.S.
• Incidence & Treatment:
– NIMH estimates that 26.2% of Americans 18 and older
suffer from a diagnosable mental illness
– Difficulty determining the level of need and numbers in
need translates to difficulty projecting funding


Managed Mental Health Care
• Understanding Managed Care, its own
vocabulary and vernacular
• Fundamentally a method of coordinating
services and paying for health care service
delivery
– Manages: access to services, types & amount of
services, and choice with a goal of containing costs


• Understanding the system of care and delivery
of services
– Qualified MH professionals
– DSM
– Reimbursement
– Authorization for Services (number of allowable
and reimbursed visits)
– Emphasis on short-term care deliver


• Managed Care from a providers perspective
• Managed Care from the perspective of an
agency staff person
• Managed Care in the public sector
• Careful consideration of restrictions, access,
response to need/demand, quality of care, and
support of clients is required


Managed Care: History
• Date back 60 years
• New Deal legislation – Medical Cooperatives
– Kaiser Permanente, 1942
• Health Maintenance Organizations supported
under Nixon
• HMO Act of 1973
• By 1991 more than 38 Million people enrolled
in HMO’s

Managed Mental Health Care: History
• Traditionally the responsibility of the public sector;
public mental health authorities
• Insurance coverage for mental illness began in the
1950’s
• Benefits are driven duration of treatment rather than
the services needed
• HMO’s began to cover mental health and substance
abuse services in the 1970’s
• Mid 1980’s brought the development of separate and
sub-contracted Mental Health Managed Care
Organizations

Managed Health Care:
Economic Analysis
• Cost containment as a goal; moderate success initially
• Economic and social changes coupled with
advancements in medicine and pharmaceuticals have
resulted in rising health care costs
• Increasing premiums create difficulties for
beneficiaries
• Reduction in market competition among MCO’s had
minimized the need to offer ‘competitive’ (lower)
costs to beneficiaries


Managed Health Care: Social Analysis
• Mental Illness understood as a result of
immorality vs. the view that it is a disease or
“problems in living”
• Market forces can solve both economic and
social problems
• Collective & societal response to health
problems vs. market mechanisms handling
health needs of the public


Political Analysis
• Multi-billion dollar industry with stakeholders at
every level of our society and community
– Clients, employers, state health officials, providers,
MCO’s, legislators, advocacy groups, the broader public,
etc.
– Competing interests, goals, ideals, result in fragmented
voices, advocacy and attempts at reform
• Clients & their families struggle; many consumers are
not organized the way beneficiaries in other programs
are traditionally organized


Managed Health Care: Social Work
• Our Roles:
– Provider
– Advocate
– Planner
• Responsibility to work for reform
• Opportunity to encourage ethical practice that
promotes quality of life and ‘least restrictive’
options

Managed Mental Health Care: Issues
• Autism & Vaccination
• Online provision of mental health services
• Mental health care for Veterans
• Mass tragedies – violence in schools,
campuses, etc.


Proposals for Reform
• Mental Health Parity Legislation
– Federal Level
– State Level


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