Just as an increasing number of states are turning to managed behavioral healthcare to rein in Medicaid costs, the National Committee for Quality Assurance has issued accreditation standards for those companies.
At the same time, the media has turned up its scrutiny of managed care for treatment of the mentally ill.
The NCQA standards were issued Jan. 27, three weeks after CBS-TV's "60 Minutes" aired a segment on managed mental healthcare. During the broadcast, Harold Eist, M.D., president of the American Psychiatric Association, said managed behavioral health companies "absolutely" try to take advantage of the mentally ill because those patients are often incapable of fighting back.
"Every time I hear of one of these cases, I vow that I will fight this scourge of managed care harder and harder because it's not care; it's managed cost, and as somebody said, mangled care,'*" Eist told interviewer Morley Safer.
Managed-care executives say Eist's views are extreme and unfounded. MCC Behavioral Care, a Cigna Corp. unit singled out for criticism in the "60 Minutes" report, said in a statement, "The vast majority of (our) cases have been handled to the satisfaction of the patients, their families, employers and providers."
In the teeth of such criticism, the NCQA's standards-supported by managed behavioral healthcare firms-attempt to define effective mental healthcare.
Managed mental healthcare companies have been in business more than a decade to help control treatment costs in employer-sponsored plans while maintaining quality.
"The coordination of care encouraged by these standards marks a turning point in efforts to manage an individual's overall health across systems of care," the NCQA said. One of the requirements is that a managed behavioral healthcare company "demonstrate well-established lines of communication between patients' primary-care physicians and their behavioral health practitioners," because that link is key to successful treatment.
An article in a recent Journal of the American Medical Association contends the NCQA's goals of collaboration between primary-care doctors and psychiatrists is "good news" for mental health providers. They have felt pushed out of the managed-care picture as many employers carved out behavioral healthcare from their group health plans, usually contracting with a mental healthcare company that monitors providers.
The NCQA standards also include requirements regarding quality improvement, accessibility, utilization management, credentialing, patients' rights and responsibilities, preventive services and recordkeeping.
The standards were developed with recommendations from employers, consumer groups, provider and managed behavioral healthcare organizations. The new standards are as rigorous as the NCQA's requirements for accreditation of HMOs, the agency said.
But Eist said the standards are "inadequate" and "minimalistic." One standard, for example, requires that a patient suffering from depression be seen within a month of discharge from a hospital. However, because "patients are being kicked out of the hospital quicker and sicker," the standard is "not only inadequate, it could be lethal," he said.
That's because if a sluggish patient is started on an antidepressant in the hospital, "before it has a profound antidepressant effect, there is some energization." Once the patient is out of the hospital, he or she is then able to act on suicidal impulses, Eist said.
"It's absolutely essential (depressed) patients be seen the same day they are discharged or the next day and be supervised by relatives," Eist said. "The majority of mental health organizations are not providing the quality of care patients need," and the NCQA standards are not adequate to correct this problem, he added.
Eist blamed such failures on managed behavioral healthcare companies' bottom-line orientation, which he called "wrongheaded."
Meanwhile, Elizabeth Cullen, assistant director for legal and regulatory affairs at the American Psychological Association, praised the standards' goal of improving communication between providers. She also likes "their focus on quality improvement, increased attention to credentialing and inclusion of a patients' rights section."
However, Cullen said there are areas where the standards are seriously flawed. "The opportunity for the NCQA was tremendous in drafting these standards . . . for looking at outcomes to ensure companies are providing quality care. I don't think these standards achieve that in a number of critical areas," she said.
The standards encourage companies to do the right things but offer no clear guidelines, she added. For example, she said no specific time line is established for companies to either make a utilization review decision or to respond to an emergency appeal when initial treatment is denied.
Cullen also criticized the standards involving patient confidentiality, saying they're "not clear and protective enough." The standards also require that psychiatrists oversee a patient's care within the managed-care system and don't allow psychologists to admit patients to hospitals.
Those requirements are inconsistent with standards of the Joint Commission on Accreditation of Healthcare Organizations, Medicare and 15 states, Cullen said.
Despite the criticism, health plans are interested in the standards, which they believe will help purchasers in selecting among competing managed behavioral healthcare companies.
Although some HMOs have in-house mental health programs, many HMOs contract with stand-alone companies for mental health services. Nineteen of those companies, which cover about 120 million lives, belong to the American Managed Behavioral Healthcare Association. It's those stand-alone companies that will go through the NCQA accreditation first, beginning in April. The mental healthcare programs of HMOs have until 1999 to receive accreditation.
Though it supports the standards, the AMBHA is concerned that the delay for HMO plans may put its members at a disadvantage in the marketplace because of the cost of going through accreditation, said Clarke Ross, the association's president.