As we put together this issue of Behavioral Health Management, with its focus on behavioral health delivery systems, I was struck by how the differences are diminishing between entities known as 'providers' and those previously called 'insurers' in the behavioral health field. The field appears to be increasingly dominated by provider-sponsored integrated delivery systems--or managed behavioral health programs that look like provider organizations.
Perhaps it was inevitable. Most health care payers--from to Medicaid to CAMPUS--have been looking reduce their health benefit costs through monitoring treatment utilization and to limit their financial risk through risk-sharing or capitation types of contracting. For a long time, behavioral health was exempt from most health care cost containment initiatives. Utilization reviews, DRGs, second opinion programs, capitation arrangements, etc. weren't applied as often to behavioral health services. And, in the early 1980s, when payers asked for similar controls on behavioral health--e.g., standard criteria for payment decisions; evaluations of behavioral health professionals and provider organizations with regard to quality and efficacy; risk-sharing contracts--the answers were not to be found in the provider community. Payers found that most behavioral health provider organizations were, at the time, unwilling to adopt standardized treatment criteria to limit health benefit payments; unwilling to make judgements about provider organizations' quality and efficacy; unwilling to move away from fee-for-service payment to risk-sharing.
Thus was born the managed behavioral health program niche. Entrepreneurial organizations, many of them founded by entrepreneurial behavioral health professionals, met those needs by developing behavioral health utilization review criteria, creating behavioral health provider networks, and entering into financial risk-sharing contracts with payers.
For the past ten years, growth enrollment in these managed behavioral health programs has increased to over half of the insured population, with ten primary programs gaining control of 90% of the market. However, a couple of interesting developments have changed the face of the field. First of all, price competition among the managed behavioral health programs has forced a re-evaluation of traditional models of managing behavioral health care. Managed behavioral health programs have discovered that it is less expensive (and better for the consumer) to make local behavioral health provider organizations a 'partner' in behavioral health plan management and profits, to have mutually-agreed upon clinical criteria for treatment planning, to leave treatment planning to the local provider partner, and to eliminate 'long-distance' (whether by telephone or by mail) approval of treatment plans. At the same time, provider organizations have discovered that applying managed care techniques to the behavioral health field is certainly challenging, but not impossible.
As a result, provider-sponsored integrated delivery systems have been organized to accept risk-based capitation contracts for behavioral health benefits, and are competing head-to-head with managed behavioral health programs. At that same time, managed behavioral health programs are backward integrating--becoming providers of care through exclusive contracts, building or buying behavioral health practices and treatment programs, or joint venturing--in order to remain competitive.
Providers becoming insurers. Insurers becoming providers. It appears that the successful behavioral health delivery systems of the near future will be risk-bearing integrated behavioral health delivery systems. This issue of Behavioral Health Management will give you some idea of how behavioral health organizations are approaching this challenge.
