 |
This Web site is a component of the SAMHSA Health Information Network. |
|
Special Report
Preventive Interventions
Under Managed Care: Mental Health
and Substance Abuse Services
Appendix A:
Preventive
Behavioral
Health, Past
and Present
How widespread, severe, and costly are mental disorders and
substance abuse problems? Consider the following:
- One-third of American adults may develop
a diagnosable mental disorder in their
lifetimes, and one adult in five is thought
to have a mental disorder at any given
time (Robins & Regier, 1991).
- An estimated 12% of all children and
adolescents in this country have one or
more mental disorders (Pelosi, 1996).
- Depression is the fourth leading cause of
illness-related disability in the world
(NIMH, 1998).
- Of the 10 major causes of disability
worldwide, half are mental disorders and
substance abuse problems (Mrazek,
1998).
- In 1996, the cost to the nation of providing
treatment for mental disorders and
the abuse of alcohol and other drugs was
$79.3 billion.
An analysis of "actual" causes of death in
the United States concluded that in 1990,
tobacco was first (400,000, or 19% of
deaths); alcohol was third (100,000, or 5%
of deaths); and illicit use of drugs was ninth
(20,000, or 1% of deaths). The authors
pointed out that health resources were being
allocated based on conditions that are
recorded on death certificates rather than
these preventable causes of mortality, estimating
the national investment in prevention
at less than 5% of total annual health care
expenditures (McGinnis & Foege, 1993).
NIMH has traced the prevention of mental
disorders to the 1930s, noting that early
efforts were based on humanitarian concerns
rather than a foundation of research.
Starting in the late 1960s, increased emphasis
was placed on the importance of creating
and building a knowledge base (NIMH,
1998).
Preventive services have been a component
of managed care for many years. In 1982,
the U.S. Department of Health and Human
Services published Guidelines for Health
Promotion and Education Services in
HMOs, which updated a 1976 document
entitled Planning Health Education in HMOs. Noted the authors, "HMOs are a
special form of health care delivery not only
because of the cost savings they achieve but
because of the opportunity they offer for
provision of preventive and health education
services" (Mullen & Zapka, 1982).
Unfortunately, behavioral health services
in general have taken a back seat to primary
medical care services in managed care contracts;
preventive behavioral services benefits
are not widely available. In recent years,
capitation for behavioral health services has
been decreasing, while restrictions on those
services have been increasing (Mrazek &
Haggerty, 1994). Data from 1997 indicate
that at least 75% of employer-sponsored
health plans restrict behavioral health coverage
more than general medical coverage
(Buck, Teich, Umland, & Stein, 1999).
Increasingly, managed care enrollees are
receiving behavioral health services from
managed behavioral health care organizations
(MBHOs), which "carve out" behavioral
health care services from other medical
care services and deliver them to a defined
population. Private-sector employers and
public-sector institutions such as Medicaid
and State mental health and substance abuse
agencies negotiate these arrangements to
control costs and to improve quality and
access for mental health and substance
abuse care (Edmunds et al., 1997). Other
models for managed mental health and substance
abuse care include the following: integrated
with other health services within a
single managed care company; left out of
MCO coverage entirely; and modified integrated
or "partially carved out" so that
enrollees receive some acute behavioral services from the physical health plan but
receive referrals to a specialty provider when
more intensive intervention is indicated
(Substance Abuse and Mental Health
Services Administration, 1998b).
A recent survey of HMOs by Conwal,
Inc., regarding its health promotion activities
found that managed health care relationships
with prevention took many forms:
(1) prevention subcontracts from the MCO
to community resources; (2) prevention
carve-outs in which the MCO is required to
support a designated specialty prevention
provider; (3) community patronage in which
prevention is provided as a "philanthropic
commitment" (Stoil & Hill, 1998, p. 21);
(4) a case referral model in which enrollees
are referred to community resources without
direct compensation; (5) strategic investment
by the MCO as a long-term community or
enrollee benefit; (6) a collaborative model in
which the MCO and community-based
organizations collaborate fully in the prevention
arena; and (7) an integrated services
model in which the MCO adopts community-
based prevention as an integral component
(Stoil & Hill, 1998).
Consumers, providers, insurers, and purchasers
are all stakeholders in decisions
about which services will be included in
MCO contracts and how they will be delivered.
Other stakeholders include constituency
groups, accrediting organizations, government
agencies, and business groups on health
(Mrazek, 1998). Several compelling reasons
motivate these stakeholders to support the
incorporation of proven, effective preventive
behavioral health programs and services into
MCO systems of care:
- It is in the public interest to prevent mental
disorders and substance abuse rather
than to wait until disease and disability
impose their burdens.
- A substantial and growing body of
research provides evidence that certain
preventive behavioral health interventions
are efficacious (that is, they work
under ideal conditions) and effective
(that is, they work under "real world"
circumstances).
- A small but developing body of multidisciplinary
research demonstrates that certain
preventive behavioral health interventions
can produce cost savings or a cost offset
(that is, the cost of the interventions is off-set
by savings from lower utilization
of other services).
- MCO accreditation standards include requirements
for some preventive behavioral
health interventions. These requirements
may increase as the evidence base expands.
Previous | TOC | Next
|
|
