Purchasing Managed Care Services for Alcohol and Other Drug Treatment
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The relatively recent emergence of behavioral healthcare companies has resulted in this type of health care being largely unregulated by both States and the Federal government. Although States and the Federal government regulate health maintenance organizations (HMOs), health insurers, and alcohol and other drug (AOD) treatment providers, few such regulations govern the activities of managed care firms. While many firms act in good faith and provide quality services to those served, some do not and thereby damage the overall reputation of the industry.
In the absence of such regulation, several problems have occurred at different times in the implementing of managed care programs. These include:
Without consumer protections in place, this combination of factors can potentially lead to inadequate and sometimes dangerous care. In response to this, the Model Managed Care Consumer Protection Act was established to provide reasonable protections to consumers. It sets a standard that allows responsible managed care firms to continue to carry out their functions, but creates much-needed consumer protections for those firms whose policies or fiscal incentives can lead to less than adequate care (President's Commission on Model State Drug Laws 1993, pp. D75-D95; D. Gates, Pennsylvania Health Law Project, personal communication, March 1994).
The following are some key consumer protection areas that should be incorporated into a contract with a managed care entity. Exhibit 3 provides sample contract language pertaining to consumer protection.
MCOs differ substantially regarding how available, specific, and/or valid their patient placement criteria are to providers and enrollees. Public access and input to these processes can lead to improved quality, accountability, and provider/consumer relations.
It is important that enrollees have reasonable access to appropriate treatment services. Systems need to be set in place to ensure this access if providers cannot, at a given time, offer these services within the formal system.
Written information from MCOs is sometimes difficult to obtain and challenging to read. It is essential that all necessary materials be readily available and be written in clear and simple language(s).
The extent to which services are covered and the amount of that coverage vary greatly. Limits on coverage can include maximum number of days, number of visits, or dollar amounts.
MCOs often have incentives to disenroll or to encourage disenrollment of individuals perceived as expensive or difficult to treat. Additionally, in highly competitive markets, MCOs sometimes use dubious procedures as they compete for enrollment.
In general, contracts should make disenrollment by the provider or MCO very difficult. This can be done by requiring that the provider or MCO take multiple and monitored steps in disenrollment, while making disenrollment by the consumer a relatively easy, single-step process (Boyer 1993; President's Commission on Model State Drug Laws 1993). All disenrollments should be documented and reviewed by the financing agency and/or the State AOD authority.
Legitimate differences of opinion regarding the clinically appropriate level, length, or intensity of care for a given problem are inevitable. Every MCO must have a user-friendly vehicle for handling appeals and grievances.
The training, experience, qualifications, and overall sensitivity of "gatekeepers" is crucial when addressing the needs of individuals with AOD problems. Gatekeeping is a central component within the managed care environment. MCOs should be required to provide ongoing training of gatekeepers.
The MCO should be able to demonstrate knowledge of all relevant Federal/State laws and governing provisions regarding AOD treatment. Such relevant laws and regulations include the Americans with Disabilities Act and confidentiality regulations.
| Openness of Systems | Appeals |
| The MCO shall use and disclose the patient placement criteria (e.g., ASAM) used by clinicians, make other contractor-specified information publicly available, an regularly elicit formal comment from involved agencies and enrollees. | The MCO, the contractor, or both will establish an efficient grievance procedure to handle complaints and grievances which cannot be resolved in the internal process. The MCO shall ensure that internal appeal and grievance processes are widely known, easy to use, timely, and not overly demanding of provider and enrollee resources. A mechanism will be in place for an AOD-credentialed, nonfinancially involved third party (e.g., State authority) to hear grievances that cannot be resolved at the MCO level. Enrolled individuals will have direct access to this third party as needed (e.g., an 800 line). |
| The MCO shall systematically meet with other specified organizations (e.g., State agencies, healthcare organizations, provider organizations, and consumer groups) to maximize the integration of necessary care across organizational boundaries. | The MCO shall develop a system to track and report on the frequency and severity of client complaints and grievances by region, provider, service type, and resolution of problem. |
| The MCO, or the contractor of the MCO, shall establish a community advisory board composed of carefully selected representatives (e.g., consumers, providers, relevant agencies, people in recovery, public health and mental health providers, and criminal justice representatives) who regularly meet with the MCO to monitor and suggest policy evolution. | Staffing and Gatekeeping |
| The MCO shall clearly inform all enrollees of any functional limitation in benefits or care. | The MCO shall ensure that all reviewers, other staff, or subcontractors involved in the determination of care shall be clearly qualified–by virtue of specified training, experience, and/or certification–to make informed decision regarding clinically appropriate AOD treatment. |
| Out-of-Plan Services | Utilization review decisions will be clinically based on "best practice" and consistent with emerging national patient placement standards (e.g., ASAM criteria). |
| The MCO will ensure that enrollees have reasonable geographic access to all appropriate services in the benefit package. Services may be delivered by a nonparticipating provider when not available in the enrollee's area from a participating provider or when the enrollee is out of the area. | Clinical decisionmaking will not be subject to any arrangements which create direct financial incentives for an individual staff person to deny or reduce care or create any conflict of interest. |
| Consumer-Friendly Materials | The MCO will ensure that admission to different levels and types of service is individually determined and based on teh clinical judgments of qualified AOD treatment professionals |
| The MCO will ensure that consumers are provided with all necessary materials to utilize the system effectively and that these materials are written in clear and simple language(s). | The MCO shall work with the State authority and other MCOs to develop a common or core set of patient placement criteria. |
| Disenrollement Protections | |
| The MCO shall not disenroll consumers based on previous claims, change class or premium status based on claims, or use any incentives to disenroll unwanted consumers. Additionally, it will seek additional enrollees in an ethical manner. |
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