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Managed care is really managed financial risk

By Daniel Fisher, M.D., Ph.D.

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I was recently asked by the director of a consumer/survivor-run social support center if they should accept money from managed care organizations (MCOs) planning to bid for the Medicaid contract in their area. They had not accepted the money because they felt it would create a conflict of interest since several of their members were helping to construct the request for proposal (RFP) with local government. I agreed, for to remain unbiased participants in the entire process of contract award, starting with the waiver, local consumer groups should not accept money from an MCO until after the contract has been awarded. Before this era of managed care, there were concerns that accepting government money would stifle the independence of c/s groups, but there was not the same level of ethical and legal concerns.

This article will focus on ways the consumers/survivors can participate ethically in the local planning of Medicaid managed care, a cost saving measure local governments are intensely pursuing. Public agencies are required by law to include consumers/survivors in their planning bodies. During the early stages of the conversion of Medicaid to managed care up to the awarding of a contract by local government to the winning MCO, these regulations still apply. After a contract has been signed between local government and an MCO, however, most states do not have legislation requiring c/s participation in planning of policies of the MCO. Therefore, after a contract has been signed, consumers/survivors need to find new ways to influence the organization. To do so requires an understanding of the goals and policies of the MCOs.

Managed care has much more to do with containing financial loss than with care, so I would call it managed financial risk. MCOs accomplish this goal either by reducing the cost and quantity of services or by reducing the chance of their being sued. I will now review some of the risk related terms used by MCOs for they reveal about the above relationships:

At RISK contracting = a contract between a company or government (the purchaser) and an MCO which passes the risk of financial loss (and the buck) from the purchaser to the MCO

Demand RISK= the risk that the people covered by the plan will demand more services than the plan can afford (this is also called utilization risk)

Human RISK management= reducing the number and intensity of demands by people seeking treatment

Liablitiy RISK= risk of MCO being sued

HOW MANAGED CARE HAS MANAGED RISK IN THE PAST

The overall risk reduction strategy is to shift the control for decision making from the doctor to the MCO. In that regard we have always had managed care. The old system of care was doctor managed care and the new system of care could be called corporate managed care. This break in professional control of care is welcomed by many people labeled with mental illness because it restores some equality in the relationship. The hope is that MCOs can help restore control of healing to each person through practices of self-managed care.

For a Listing of Warmlines, visit www.warmline.org

When MCOs operated solely for private industry, one of their primary risk reduction techniques was to exclude people considered a high medical or behavioral risk from their plan. Now that these MCOs are contracting with public entities, they are required to cover those people at risk and they are needing to reduce costs by reducing the demand for services by those people without being sued. This requires two conflicting policies on the part of the MCOs. To reduce the risk of a law suit, they have turned to highly credentialed professionals (doctors and psychologists), providing research based services (medication and cognitive/behavioral therapy), under narrow medical necessity criteria, in traditional settings (hospitals and clinics). They are, however, more costly and less likely to lead to recovery. To reduce financial risk, however, MCOs need to use less credentialed professionals (peer counselors), providing innovative services (warm lines, social clubs, holistic), for broader psychosocial necessity reasons, in nontraditional settings (clubs, apartments). One way out of this conflict is to increase the degree of consumer involvement in their own treatment and in the running and evaluation of services.

SELF-MANAGED CARE: HOW CONSUMER INVOLVEMENT CAN REDUCE RISK

Some MCOs understand the cost savings of self-help and are interested in encouraging providers to refer consumers to self-help groups. They do not, however, understand the values underlying self-help and the degree to which provider practices perpetuate dependency. There is a need for consumers to teach the MCOs and their providers ways that providers can collaborate with consumers. Consumers in recovery can play an important role in training providers how to shift from paternalism to collaboration.

Consumer involvement at the individual level can be improved by consumers training providers in the following areas:

  1. An empowerment and recovery oriented treatment approach to working together which emphasizes hope, self-determination, meaning, and individuality as outlined by many consumer/survivor writings and videos.
  2. Rehab approach centered on consumer-defined goal setting and outcome studies.
  3. Providing materials on coping (such as "Coping with Voices") and Self-Managed Care (A Manual for Consumers, available through NEC).
  4. Informed consent policy of discussing benefits and risks of traditional and complementary medicine approaches.
  5. Use of advance directives stating preferences in the event of a crisis.

Consumer/survivors can also play important roles at the group level in risk reduction through service provision, training and planning. In order for consumer groups to work with MCOs they need to be respected and engage in collaborative planning. There is a risk on the part of consumer groups of being used by the MCO who might pay them to keep their criticism down, to get cheap labor, or to get their support in future bids. I would recommend caution in entering into working contracts with the MCOs. I suggest the following guidelines for consumers who agree to accept money from an MCO for services that could lead to an increase in the profits of the MCO:

  1. Do not accept money from an MCO until the bids have been reviewed.
  2. If an MCO makes contact with a consumer or consumer group, contact other consumers, and form a coalition; do not go it alone.
  3. Hold planning meetings between the consumer coalition and the MCO before making promises.
  4. Initially choose areas of work in which consumers have some experience and about which there is written documentation by consumers, such as:
    1. Consumer-run trainings for the MCO staff to raise their awareness regarding empowerment and recovery (this should be a starting point)
    2. Consumer-run social clubs
    3. Consumer-run warm lines for support, information, and linkage to self-help groups
    4. Consumer-run satisfaction teams
  5. Draw up a contract between the MCO and the lead consumer group. The contract would clearly describe the services to be performed by the consumer group and the money the MCO would pay for them. In addition there should be a provision in the contract for profit sharing. If the efforts of the consumer group result in a cost reduction, 50% of those savings should go back to the consumer group. Have a lawyer review the contract.
  6. Establish a means of recording services performed which both meets the needs of the MCO to validate that their beneficiaries are being served and the needs of the recipients to be free from telling their story and labeled other than that they have mental illness.
  7. Ensure that the MCO will seek out consumer participation in the design and carrying out of outcome measures and satisfaction surveys of their own work and that of providers in areas related to theirs.
  8. Expect the service to be paid at a decent rate. Ensure that there is adequate money and personnel for training and supervision.

CONSUMER SELF-MANAGED CARE IN MASSACHUSETTS

A new managed care company, Massachusetts Behavioral Health Partnership (MBHP), a joint venture of Options FHC and Value Behavioral, took over the contract to cover 400,000 "Medicaid lives" on July 1, 1996. They outbid the incumbent MHMA and three other companies. The RFP requires that there be a consumer council to the purchaser and that consumers and families be involved in the construction of the Quality Improvement Program. NEC has joined a coalition of consumers/survivors, families, and legal advocates to periodically monitor the new MCO. We recently met with the Commissioners of Mental Health and Medicaid. They assured us that there would be an accessible grievance procedure and there would be c/s and family involvement in Quality Improvement.

The director of prevention for MBHP contacted NEC recently as a follow-up to our recent recommendations. He said they were interested in advance directives. I immediately called a meeting of the local consumer groups. We plan to say we would like to see a warm line funded by the MCO.

It is important for c/s's to have access to information regarding the stage of managed Medicaid and Medicare in their states. The Health Care Financing Administration (HCFA) prepares that information and it can be obtained through NEC. For example, NEC was recently informed by HCFA that the New England states are forming a consortium to convert the mental health care of recipients on Medicaid and Medicare to managed care. This information was not available at the local level, so there has not been significant c/s involvement in any of the initial planning. NEC plans to ensure c/s participation in these plans by connecting the local consumers with the state officials drawing up the plans.