Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)


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Solutions within managed care have included higher copayments and deductibles, aggressive utilization review, and outright termination of mental health coverage.

The Silent Shortage

In many instances, HMOs appear to have spent more time and energy managing reimbursement and utilization than managing the overall care of their enrollees. Prepaid reimbursement provides the best and worst incentives for the delivery of services for persons with chronic problems—especially psychiatric care. Capitated prepayment has the potential to reduce institutional care, improve coordination of services, and promote the prevention of future illness or episodes of care. This places an already vulnerable population at even greater risk for being managed toward the bottom line rather than toward improved clinical outcomes.

When treatment is required over an indefinite or unpredictable period of time and there is little clinical consensus on the exact constellation of required services, HMOs will be tempted to restrict services through limitations and ceilings on benefits. The incentives to cut losses incurred under such unpredictable circumstances require an aggressive effort within HMOs to scrutinize the essentials of the mental health care delivery system through population-based care management and experiments with financial incentives that reward improvements in health status including mental health status rather than strict adherence to policy exclusions and limits.

HMOs have a unique opportunity to provide health care services for a defined population that has a known set of epidemiologic characteristics. Clinicians in HMOs can use population-specific data to design a range of treatment alternatives that match the needs of enrollees. Patient- and system-level interventions then can be activated to meet the needs of untreated or at-risk persons. Primary care providers can routinely screen for depression, identify unusual patterns of service use for example, high use in the absence of other indications , and pursue alternative etiologies, such as undiagnosed mental disorders, among their patients.

Population-based programs can be designed to provide a spectrum of treatment alternatives for enrollees who are mentally healthy such as employee assistance programs, stress management, and family counseling or mentally ill such as partial hospitalization, day care, and medication management. Staff can monitor patient outcomes such as improvements in functioning, lapses in treatment, noncompliance with medication orders, or unexpectedly high use of services in other parts of the system. Patients who require follow-up for medication management or simple telephone check-backs can be flagged; automatic reminders and follow-up appointments can be generated through automated protocols that are activated at designated intervals.

In-house program evaluators and academic researchers can study the cost-effectiveness of a variety of treatments for persons with a range of mental health complaints.

Can Separate Be Equal? Ending the Segregation of Mental Health

They can demonstrate to the host organizations the costs of untreated depression or the impact of premature termination of benefits or changes in copayments, so that benefits and direct patient care services can be based on effectiveness, rather than on the fear of uncontrollable costs. Population-based management means that primary care physicians are more likely to look for untreated mental health problems such as depression and anxiety in their practices.

We have seen from previous research that perceived and actual lack of service capacity is a significant deterrent to referrals to specialty mental health services in HMOs. There are few, if any, treatment environments in which aggressive care management can be monitored as thoroughly as in HMOs. The potential power of the technology must be mediated by explicit financial disincentives or the lack of incentives to skimp on services.


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Systems of care that give direct salary incentives, bonuses, or penalties to providers based on the volume of care they produce should be carefully scrutinized. Financial self-interest simply should not be played against obligations to patients. Network models now exist in which payment for services is withheld or prorated based on the success of treatment or management of symptoms. These programs, which are now entering the marketplace, may revolutionize the way we reimburse mental and physical health services. Even without such a radical departure from current reimbursement methods, it is clear that we discourage many people with serious mental disorders from obtaining services from HMOs through high initial copayments, low benefit limits, and inadequate risk adjustment methodologies that underestimate the cost of their care.

To address some of these concerns, the Harvard Community Health Plan HCHP eliminated copayments for mental health services so that high-risk patients would not be discouraged from seeking needed services. Gilberman, M. Practice areas and settings of social workers in mental health. Psychiatric Services , 46, Hausman, J. Specification tests in econometrics.

Econometrica , 52, Health care plan design and cost trends: - Washington, DC: Author. Ivey, S. Supply dynamics of the mental health workforce: Implications for health policy. The Milbank Quarterly , 76, Jensen, G. The new dominance of managed care: Insurance trends in the s. Mental health insurance in the s: Are employers offering less to more?

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Collaborative management to achieve treatment guideline: Impact of depression in primary care. JAMA , , Lambert, D. Political and economic determinants of insurance regulation in mental health. Journal of Health Politics, Policy, and Law , 15, Mechanic, D. Changing patterns of psychiatric inpatient care in the United States: Archives of General Psychiatry , 55, Meyer, R. Managed care and the role and training of psychiatrists.

Information

Health Affairs , 14, Narrow, W. Use of services by persons with mental and addictive disorders: Findings from the NIMH epidemiological catchment area study. Archives of General Psychiatry , 50, National Resident Matching Program. NRMP data.

Vandrevala Foundation

National Science Foundation. Survey of earned doctorates. Appendix Table A Olfson, M. Outpatient mental health care in nonhospital settings: Distribution of patients across provider groups.

American Journal of Psychiatry , 10, Pincus, H. The structure of psychiatrists' outpatient practice. Psychiatric Services , 49, Prescribing trends in psychotropic medications: Primary care, psychiatry, and other medical specialties. Who they are: Licensed psychologists have their doctorate degree a PhD or PsyD and undergo extensive training before opening a practice in the US.

It can take seven years to earn that degree; after that, states require 1, to 6, hours of supervised training with patients—often followed by an exam. Psychologists can diagnose mental health conditions and provide counseling. But in five states, psychologists who undergo extra training can also prescribe some medications. Training: Rules vary in states that allow psychologists to prescribe. In New Mexico, requirements include hours of instruction plus hours of supervised practice.


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Illinois requires training in psychopharmacology plus 14 months of full-time training in a variety of mental health locations including hospitals and clinics. According to the Illinois Psychological Association, prescribing psychologists are especially aware of non-drug approaches to mental health issues and are less likely to prescribe drugs than other psychiatric healthcare practitioners.

Telepsychiatry could help solve the physician shortage. But are video mental health visits as good as in-person appointments? Does health insurance cover them? A home-bound year-old with schizophrenia gets her first psychiatrist check-up in 20 years. A young boy with attention deficit hyperactivity disorder visits his psychiatrist from the familiar comfort of his elementary school.

Texas police deputies get real-time help for people undergoing a mental-health crisis, via iPads that connect them with mental health practitioners. One University of Missouri study found that video visits for kids and teens saved some families from driving hundreds of miles to get care. A West Coast study of rural military veterans with post-traumatic stress disorder—a program now being studied across the US—provided effective treatment without requiring veterans to make long trips, too.

Telepsychiatry could help you get a psychiatric evaluation and treatment plan more quickly and conveniently for a mental health issue like depression, anxiety or others. Rules vary by insurance plan. And state and federal laws and regulations about telemedicine coverage which includes telepsychiatry also vary wildly. Insurers and regulators have to catch up. Things are improving. About 40 states and the District of Columbia require private insurers to cover telepsychiatry in some way [ 27 ][ 28 ] —up from 38 in Medicaid coverage for telehealth is different in every state; some require you to have your video visit from a medical office but visits from home are covered in about 36 states.

Just who can provide those visits also varies by state under Medicaid. The easiest way to find out what your health insurance covers—and how to access telepsychiatry is to call your insurance company and ask. Benzion Blech, who studied the psychiatrist shortage in the Washington, DC, area for a study.

I suspect that, as telemedicine technology continues to improve, telepsychiatry encounters will become more and more common. For patients unable to travel to psychiatrist locations, or have disabilities that prevent or limit travel, this is a great option. Researchers are finding that telemental health care can be as good as or better than in-person care for depression, anxiety, anger management, eating disorders, alcohol abuse, post-traumatic stress disorder, and other mental health concerns, according to an August report from the National Telehealth Policy Resource Center.

Psychiatrists talking with their patients via video have been able to make a mental health diagnosis as accurately as a psychiatrist in the room with the patient, according to a study from the Carillon Clinic in Roanoke, VA, of 73 people who came to a hospital emergency room with depression, substance abuse, anxiety and bipolar or psychotic disorders. ADHD in the Workplace.

Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care) Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)
Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care) Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)
Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care) Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)
Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care) Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)
Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care) Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)
Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care) Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)
Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care) Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)
Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care) Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)
Treatment Of Depression In Managed Care (Mental Health Practice Under Managed Care)

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