Managed Care and Mental Behavioral Health CEUs

Managed Care and Mental Behavioral Health CEUs
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1. Define and become familiar with the fundamentals of managed care
2. Learn the history of managed care
3. Identify managed care program types
4. Learn and distinguish important national managed care laws
5. Utilize applicable managed care resources

Table of Contents:
1. Definition
2. History
3. Managed Care Program Types
4. Outcomes
5. Legal Updates
6. References

1. Definition

Managed care plans are health insurance plans that contract with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network. How much of your care the plan will pay for depends on the network's rules.
Restrictive plans generally cost less. More flexible plans cost more. There are three types of managed care plans:
• Health Maintenance Organizations (HMO) usually only pay for care within the network. You choose a primary care doctor who coordinates most of your care.
• Preferred Provider Organizations (PPO) usually pay more if you get care within the network, but they still pay a portion if you go outside
• Point of Service (POS) plans let you choose between an HMO or a PPO each time you need care
The term managed care is used to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care ("managed care techniques") organizations that use those techniques or provide them as services to other organizations ("managed care organizations"), or systems of financing and delivering health care to enrollees organized around managed care techniques and concepts ("managed care delivery systems"). According to the National Library of Medicine, the term "managed care" encompasses programs “intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.” The growth of managed care in the U.S. was preceded by the enactment of the Health Maintenance Organization Act of 1973. While managed care
techniques were pioneered by health maintenance organizations, they are now used by a variety of private health benefit programs. Managed care is now nearly ubiquitous in the U.S, but has attracted controversy because it has largely failed in the overall goal of controlling medical costs. Proponents and critics are also sharply divided on managed care's overall impact on the quality of U.S. health care delivery (Peter R. Kongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001, ISBN 0-8342-1726-0).

In his analysis of the American health care system (i.e., The Social Transformation of American Medicine), Paul Starr suggests that Ronald Reagan was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of HMOs, the first form of managed care. Managed care plans are widely credited with subduing medical cost inflation in the late 1980s by reducing unnecessary hospitalizations, forcing providers to discount their rates, and causing the health-care industry to become more efficient and competitive. Managed care plans and strategies proliferated and quickly became nearly ubiquitous in the U.S. However, this rapid growth led to a consumer backlash. Because many managed care health plans are provided by for-profit companies, their cost-control efforts created widespread perception that they were more interested in saving money than providing health care. In a 2004 poll by the Kaiser Family Foundation, a majority of those polled said they believed that managed care decreased the time doctors spend with patients, made it harder for people who are sick to see specialists, and had failed to produce significant health care savings. These public perceptions have been fairly consistent in polling since 1997. The backlash included vocal critics, including disgruntled patients and consumer-advocacy groups, who argued that managed care plans were controlling costs by denying medically necessary services to patients, even in life-threatening situations, or by providing low-quality care. The volume of criticism led many states to pass laws mandating managed-care standards. Complying with these mandates increased costs. Meanwhile, insurers responded to public demands and political pressure by beginning to offer other plan options with more comprehensive care networks--according to one analysis, between the years 1970 and 2005 the share of personal

2. History

health expenditures paid directly out-of-pocket by U.S. consumers fell from about 40 percent to 15 percent. So although consumers faced rising health insurance premiums over the period, lower out-of-pocket costs likely evidence encouraged consumers to use more health care. Data indicating whether this increase in use was due to voluntary or optional service purchases or the sudden access lower-income citizens had to basic healthcare is not available here at this time (Peter R. Kongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001, ISBN 0-8342-1726-0).

By the late 1990s, U.S. per capita health care spending began to increase again, peaking around 2002. Despite managed care's mandate to control costs, U.S. healthcare expenditures has continued to outstrip the overall national income, rising about 2.4 percentage points faster than the annual GDP since 1970. Nevertheless, according to the trade association America’s Health Insurance Plans, managed care is nearly ubiquitous in the U.S.; 90 percent of insured Americans are now enrolled in plans with some form of managed care. The National Directory of Managed Care Organizations, Sixth Edition profiles more than 5,000 plans, including new consumer-driven health plans and health savings accounts (Peter R. Kongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001).