Psychological Testing in the Age of Managed Behavioral Health Care

Mark E. Maruish, E. Anne Nelson

• Publisher: Routledge
• Year: 2001
• eBook ISBN: 9781135656331
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Written by a recognized expert in assessment employed by a large managed behavioral healthcare organization (MBHO), this book seeks to provide psychologists who rely on testing as an integral part of their practice, a guide on how to survive and thrive in the era of managed behavioral healthcare. It also offers ideas on how to capitalize on the opportunities that managed care presents to psychologists. The goal is to demonstrate that despite the tightening of the reins on authorizations for reimbursable testing, psychological testing can continue to play an important role in psychological practice and behavioral healthcare service delivery.

The book presents ideas for:
*increasing the likelihood of getting tests authorized by MBHOs;
*using inexpensive/public domain assessment instruments;
*ethically using psychological testing in MBHO settings;
*capitalizing on the movement to integrate primary care and behavioral healthcare through the use of psychological testing; and
*designing and implementing outcomes assessment systems within MBHO settings.

Intended for practicing psychologists and other behavioral health practitioners employed by MBHOs in direct service delivery, care management or supervisory positions, as well as for graduate clinical or counseling psychology students who will most likely work in MBHO settings.

1
Introduction

Probably in no other period in time has so much change in the field of health care taken place than during the past century. Breakthroughs and technological advances in the diagnosis, treatment, and prevention of diseases abounded during the 20th century. Never has so much progress occurred in such a relatively short period of time than what we have just witnessed. But at the same time, never have so much controversy, debate, and upheaval surrounding this country’s health care delivery system taken place as have occurred during the past decade. Out-of-control costs and the delivery of inefficient and sometimes ineffective services have led to drastic changes in this country’s health care delivery system. Few would disagree that the most drastic of these changes has been the introduction of what is referred to as “managed care.” This system not only affects the way treatment for physical problems is delivered but also the way in which behavioral health care—mental health and substance abuse services—is provided. Indeed, managed care has become the dominant force in the delivery of mental health care services (Cushman & Gilford, 2000). Depending on one’s point of view, the effects may be considered positive or negative. However, the general opinion that one is likely to uncover about managed care is a negative one.

All behavioral health care professions have been affected by managed care, not the least of which is psychology. The extent to which the effects of managed care on psychology are perceived as threatening to its practice and the people who seek its services can seen in the American Psychological Association’s support of legislative and judicial efforts that seek to curb managed care policies and practices. One area of psychological practice that has been significantly affected by managed care is psychological testing—the one truly unique and (some would argue) defining aspect of psychology among the behavioral health care professions. Indeed, the importance of psychological testing to the field’s identity and, more significantly, the contribution this activity can make to the ultimate well-being of those whom the profession serves through a system of managed health care is the impetus for the development of this book.

To fully appreciate how psychological testing can become an integral component in a managed system of health care, first it is important to have a good working knowledge and context of what we call “managed care”: what it is, how it came into being, how it has impacted behavioral health care services and the profession of psychology, and how it is likely to change and impact behavioral health care in the future. This chapter is intended to provide that context and to set the stage for the chapters that follow.

A BRIEF INTRODUCTION TO THE BASICS OF MANAGED CARE

Managed behavioral health care is both a reflection and an outgrowth of the system of general managed health care that preceded it. Thus, to better understand managed behavioral health care and its impact on the psychologists’ practices, it is important first to better understand managed care in general.

What Is Managed Care?

It is important to understand what is meant by “managed care.” The term has come to mean different things to different people. The variability in perceived meaning of the term is great, with discrepancies being the greatest between groups of health care consumers and groups of health care providers and provider organizations.

There is no shortage of conceptualizations of the term in the professional literature. Some are very general, such as Benedict and Phelps’ (1998) definition of managed care as “the collective term for the myriad cost-containment strategies and financing arrangements currently dominating this country’s evolving health care system” (p. 29). United HealthCare (1994) defines it as “a system of health care delivery that influences utilization and cost of services and measures performance. The goal is a system that delivers value by giving people access to quality, cost-effective health care” (p. 45).

There are other conceptualizations that are slightly more detailed. Ford (2000), for example, describes managed care as

a comprehensive approach to health care delivery that encompasses planning and coordination of care, monitoring of care quality, and cost control. Managed care uses systems to approve the delivery of service before they are provided (prior authorization and concurrent review). It also includes new systems of financing health care delivery, such as placing providers, rather than the insurer, financially at risk for the cost of service delivery. (p. 311)

With any more specificity and detail, the definition of managed care is likely to be descriptive of a particular type of managed care. The various types of managed care arrangements that are available to health care consumers will be discussed later in this chapter. However, for the general purpose of this chapter, Ford’s (2000) conceptualization of managed care will serve as a good reference.

An Historical Perspective

Like many others, Miller (1996) views the impetus for the rise of today’s system of States during the 20th century. The increase of health care expenditures from 6% to tional indemnity or fee-for-service insurance system that was prevalent in the United managed care as the health care cost increases that were appearing under the tradi12% of the gross national product between the years 1965 and 1990 is cited as evidence of the failure of indemnity plans to control costs. This should not be surprising, given that indemnity plans reimburse care providers on the basis of the number and types of services they offer. This has the unintended effect of encouraging plan members to seek more services, and practitioners and facilities to provide more services (Edmunds, Frank, Hogan, McCarty, Robinson-Blake, & Weisner, 1997). Managed care came about as a solution to the skyrocketing health care costs that resulted from the widespread indemnity plans. How would this be accomplished? As Miller stated,

The essential features of managed care do not restore cost consciousness to consumers; rather, these features attempt to correct the incentive problem by creating two additional alterations in the market economics. First, a new party, either a managed care company or a provider with a capitated contract, replaces the consumer in evaluating the cost versus the value in health care decisions. Second, this new party has the incentive, either directly or indirectly, of increased financial success when treatment costs are reduced. (pp. 350–351)

It is commonly thought that managed care is a relatively recent movement in health care delivery. The fact is that managed care has been around since the first prepaid group practices sought to improve the quality and coordination of care and increase efforts toward prevention in the 1930s (Edmunds et al., 1997). These might be considered the first health maintenance organizations, or HMOs (see later). Managed care began to thrive in the 1970s when federal legislation authorized HMOs and loosened previously imposed restrictions (Hoge, Thakur, & Jacobs, 2000). The Center for Substance Abuse and Treatment (CSAT; as noted in Edmunds et al., 1997) reported that since the mid-1980s, managed care has gone through three phases in its approach to health care delivery. The first phase focused on the implementation of procedures such as utilization review and preadmission certification to limit access to care. Utilization review, fee-for-service provider networks, selective contracting, treatment planning, and managed benefits characterized the second phase. During the third phase, the focus shifted to managing care through an emphasis on appropriateness of care. Edmunds et al. also identified yet another phase, one in which the outcomes of a full continuum of treatment are managed through an integrated system of services. In addition, Hoge et al. have identified an emerging fifth phase that is consistent with this author’s observations. This is a focus on illness prevention and health promotion.

Types of Managed Care

As Edmunds et al. (1997) point out, there are many different types of managed care plans or arrangements. However, there are a few commonalities among them. They all employ explicit criteria for selecting practitioners and facilities to provide specific health care services to plan members under specific contractual arrangements, and members have financial incentives to use the plan’s providers and procedures. They also have established formal programs utilization review, quality assurance, and quality improvement programs. It is the administrative and benefit features that distinguish the numerous types of managed care organizations and plans from another. The distinctions among the plans and organizations allow them to be grouped within a generally accepted typology. Following are some of the more common types of managed care organizations.

Health Maintenance Organizations (HMOs). Managed care and health maintenance organizations (HMOs) were essentially synonymous until the 1980s when other forms of managed care began to appear (Harwood, Beutler, Fisher, Sandowicz, Albanese, & Baker, 1997). The HMO is still viewed as the most common type of managed care organization (Kent & Hersen, 2000). Broadly defined, it is “an entity that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium” (UHC, 1994, p. 38). Characterizing the various forms of HMOs are the provision of all health care services for a flat capitation fee, commonly paid to the service provider on a per member per month (PMPM) basis. For this fee, the provider agrees to go at risk of losing money to provide the contracted services. Utilization management and review are employed to monitor and control the utilization of member services.

There are four basic models of HMOs (Harwood et al., 1997; UHC, 1994). In the staff model, the providers of care are salaried employees of the HMO who may receive additional financial incentives for profitability or performance. HMOs employing a group model contract with a specific group of practitioners to provide services for a per-member capitated fee. The main difference between this model and the staff model is that the services may be offered at either a single location or at the practitioners’ offices. In the model of independent practice associations, or IPAs, there is a contract with a large number of providers to deliver services from their own locations for a capitated or reduced fee. The IPA then contracts with the HMO to provide services to its members for a somewhat higher capitated fee. In a network model, the HMO contracts with individual practitioners and groups of practitioners to provide services to the plan members in their offices with little if any reliance on centralized clinics.

Preferred Provider Organizations (PPOs). These organizations consist of a network of providers that agrees to treat participating plan members, sometimes at reduced fees. They may also see patients other than those in the contracted plan. Plan members may see practitioners other than these “preferred providers” but usually with a copayment, or one that is higher than that required for a preferred provider visit. According to Harwood et al. (1997), PPOs are particularly beneficial to psychologists because they provide a steady stream of referrals, are prompt in their payments, and afford the psychologist opportunities to sit on the board of directors for PPO policy and be both a broker and participant in the organization’s profits.

Employee Assistance Programs (EAPs). Although sometimes not considered managed care organizations, employee assistance programs (EAPs) often function like capitated programs in offering behavioral health crisis intervention, problem assessment, brief treatment, and referral services to a company’s employees and their families (Harwood et al., 1997). Those staffing the EAP may be employees of the company or contracted professions from the community. Depending on the EAP, the services may be offered in offices housed at the work site, or they may be offered at the site of contracting service providers. The services offered by EAPs are limited, with the focus on brief interventions and referral to an outside provider in those cases requiring more extensive interventions.

Point-of-Service Plans (POSs). Edmunds et al. (1997) describe point-of-service plans (POSs) as having features of both HMOs and PPOs. These plans maintain a network of providers through a capitation or fee-for-service reimbursement arrangement. As with PPOs and certain HMO plans, plan members incur higher financial penalties for going to providers outside the network.

Administrative Services Only Programs (ASOs). Large, self-insured employers commonly use administrative services only programs (ASOs; Bobbitt, Marques, & Trout, 1998). Here, care for plan members is arranged for by the ASO. It provides the administrative services necessary for plan members to obtain needed care. A third party—the member’s employer, for example—assumes financial responsibility for the care.

THE EMERGENCE OF MANAGED BEHAVIORAL HEALTH CARE ORGANIZATIONS

Managed behavioral health care organizations, or MBHOs, did not accompany managed care (in the more global sense of the term) as it began to exert its presence in and influence on the field of health care service delivery. It might be considered a relatively new development in the ever-evolving field of health care, but its impact has been nonetheless significant on the delivery of services to that segment of the population with mental health or substance abuse problems.

Behavioral Health Care: Managed Carve-Outs

The delivery of behavioral health ...

Table of contents

• Contents
• Preface
• Acknowledgments
• 1 Introduction
• 2 Potential Applications of Psychological Testing
• 3 Authorization of Psychological Testing and Assessment
• 4 Psychological Test Instruments, Technology, and Criteria for Their Selection
• 5 Useful Psychological Measures for Managed Behavioral Health Care Systems
• 6 Issues and Considerations in Developing Test-Based Outcomes Assessment Programs
• 7 Implementing Test-Eased Outcomes Assessment Systems
• 8 Applications and Opportunities in Primary and Integrated Care Settings
• 9 Ethical and Professional Issues
• References
• Author’s Note
• Author Index
• Subject Index