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:
Robinson Beale, chief medical officer at OptumHealth Behavioral
Solutions, a division of UnitedHealth Group and the countryís
largest managed behavioral health care company.
Pearson, a health benefits consultant who helps major employers
design their health coverage.
Groshong, director of government relations for the Clinical
Social Work Association (CSWA).
Sewell, vice-president of clinical and counseling services at
Ceridian, one of the largest EAP companies in the country.
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?
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.
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.
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
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
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.)
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.
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.
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.
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.
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.
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.)
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.
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
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.
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
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.)
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,
1) Rhonda Robinson Beale, OptumHealth Behavioral Care--via
Brad Lotterman, (714)445-0453, email: firstname.lastname@example.org; 2)
Laura Groshong, CSWA, Seattle, WA, (206)524-3690,
www.lauragroshong.org; 3) Joan Pearson, Bainbridge Island,
WA, (206)842-5324, email: email@example.com.