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Four industry insiders assess trends in the field

Most of our managed care articles are focused tightly on the providerís world: dealing with day-to-day managed care problems; getting paid; figuring out which companies are growing or shrinking or changing their policies. But periodically, we like to get broader view. In this report, we chat with four industry experts:

1. Rhonda Robinson Beale, chief medical officer at OptumHealth Behavioral Solutions, a division of UnitedHealth Group and the countryís largest managed behavioral health care company.

2. Joan Pearson, a health benefits consultant who helps major employers design their health coverage.

3. Laura Groshong, director of government relations for the Clinical Social Work Association (CSWA).

4. Jennifer Sewell, vice-president of clinical and counseling services at Ceridian, one of the largest EAP companies in the country.

Together, they provide a look at the managed care industry that providers probably donít see from inside their own offices.

The implementation of health reform laws are inspiring a renewed effort to cut costs and improve efficiency. Of course clinicians might respond: When were managed care companies not interested in cutting costs? But Rhonda Robinson Beale tells us that Optum and other major companies anticipate that parity and other reform laws will require them to change the way they provide services to their employer-clients. For instance?

-- A genuine move toward medical-behavioral integration, as opposed to the theoretical integration theyíve been talking about at industry meetings over the last 20 years. She predicts the expansion of truly integrated practices--with full-time staff that includes physicians, nurses, and behavioral health clinicians.

-- Growth in the use of capitation and case rates to reimburse these super-groups. Beale says OptumHealth is doing business this way right now with some large integrated practices in California. She sees this expanding to other parts of the country as employers demand more one-stop service options. "The practice itself would be accountable for not only the care itself, but also the cost of the care," says Beale. This represents the kind of "administrative download" that behavioral health providers were told theyíd have to deal with 15-to-20 years ago. It didnít actually happen then--but Beale insists it will this time.

-- Outcomes measurement with teeth. Beale says that 27% to 30% of OptumHealthís network providers are now using the companyís "Wellness Assessment" tool. Those who show efficient treatment patterns will find that their names "pop up more prominently among our members who are seeking care, and also among our care advocates who are referring members to providers. They will become preferred." She expects the assessment tool to be implemented across the entire Optum network over the next couple of years.

-- Actual use of, and reimbursement for, telehealth--not occasionally or in emergencies, but routinely. Beale says OptumHealth will soon begin reimbursing network providers for phone work, or online work, as a matter of course. "We have some pilot programs that are already implementing some of those arrangements...Itís the wave of the future."

-- A much greater focus on EAP and wellness programs. "Weíre getting more and more requests from our customers to create health risk assessments that are focused on identifying conditions like stress that impact productivity," she says. OptumHealth acquired two EAP companies in the past year. "Weíre definitely expanding our EAP capability on a global basis. Employers have their workforces all over the world, so we have to be able to service them wherever they are." (For more on EAP scene, see Jennifer Sewellís comments in the boxes above.)

-- Medicaidís going to become more important. Since health care reform calls for a 16% increase in Medicaid enrollees, this will be a primary source of growth for Optum over the next several years, Beale says.

The impact of parity is a major agenda item for employers, weíre told by Joan Pearson. Itís already making a "huge impact," she tells us, and itís still brand new. Although the parity law passed in 2008, the regulations werenít finished until February of 2010, and didnít go into effect until last summer. "Theyíre really going to turn managed behavioral health care upside down," she predicts.

Pearson was chief behavioral health analyst for mega-consulting firm Towers-Perrin until a couple of years ago. Now working independently, Pearson says that among her clients--employers, that is--costs and data requirements growing out of parity are the big agenda items.

And like Beale, she sees closer integration of medical and behavioral health care as an inevitable consequence. "Mental health treatment has been curtailed for some time. The only way to deal with it is to line it up with medical benefits," Pearson says.

For that reason, she goes on, specialty behavioral health carve-outs like Magellan will be at a competitive disadvantage when they bid for contracts against companies like Aetna Behavioral Health and CIGNA Behavioral Care, which are part of insurance giants that can manage the entire health care benefit. Administration of care under parity will require pulling behavioral health and medical care under one roof, she states.

One problem carve-outs face is incompatibility of information technology. Another is the reluctance of separate vendors to share proprietary information. And regulation is becoming increasingly complex, too. Insurers are having to deal with regs set forth by the Department of Health and Human Services, and also by the IRS and the Department of Labor.

Patient data would flow more easily between the medical and behavioral sides if these services were provided by one company. "I think itís going to put most of the care-outs out of business," says Pearson. (Itís important to remember, however, that experts have been predicting this for at least 10 years now. Nevertheless, Magellan is still here.)

And parity will cost money, Pearson goes on. The Congressional Budget Office estimates that mental health parity will add about .4% to the cost of mental health treatment. Of course, the mental health portion of the pie is tiny--estimated to be as little as 1.3% of overall health care expenditures. Even so, there is some new money entering the behavioral health system.

Network clinicians will see none of that, Pearson insists. Expect no fee increases, she says. "But consumers will have more access to services, which is a good thing."

For the most part, therapists havenít seen an increase in fees in about 15 years, Pearson says--which is exactly what PsyFin surveys have shown. The only bright spot, she adds, is that out-of-network providers may be able to demand more money. (On the other hand, over at OptumHealth, Beale says the companyís use of out-of-network providers has remained steady--and she sees no increases on the horizon.)

Laura Groshong from the CSWA sees things a little differently. Sheís neither as pessimistic as Pearson when it comes to provider reimbursement, nor as certain as Beale is that health reform measures will be fully implemented. The best case scenario, she tells us, is that health reform will benefit both consumers and providers. Because the law caps what insurers can spend on "administration," she feels more money could flow to care delivery--with some of it landing in providersí pockets.

On the other hand, she points out, congressional Republicans are looking to roll back a large part of the law. Even if that effort isnít entirely successful, she says, they could block funding for implementation.

Hereís another wildcard, according to Groshong: The reform law offers more money for physicians who participate in a federal program to develop electronic patient records--$44,000 is available to eligible providers in multi-year stages. Currently, non-MD providers arenít eligible, but there are two bills in Congress that would change that, Groshong says. (Thatís something weíll be following up on in the months ahead.)

Groshong also has her eye on pending Medicare cuts that will go into effect unless Congress again opts to delay them. A 23% reduction is on the table and the issue is unlikely to be a priority for the lame duck Congress in 2012. "Itís possible that for the first time, there will be a big cut in incomes" for Medicare providers, Groshong concludes.

Contacts: 1) Rhonda Robinson Beale, OptumHealth Behavioral Care--via Brad Lotterman, (714)445-0453, email:; 2) Laura Groshong, CSWA, Seattle, WA, (206)524-3690,; 3) Joan Pearson, Bainbridge Island, WA, (206)842-5324, email:



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