Managing Managed Care

The introduction of the concept of managed care into mental and physical health care appears to be a juggernaut of unparalleled impact. The two extremes of thought about this impact are (I) that managed care is a villainous foe to be resisted in order to bring back the earlier halcyon years of independence in practice decisions with greater reimbursement for psychologists' services or (2) that managed care is a laudatory attempt to restrain health care costs that are out of control and spiraling upward by rooting out mismanagement and reversing financial incentives to provide unnecessary care. The former view calls managed health care such names as "mangled care" and distributes bumper stickers stating "Just Say No to HMOs. " The latter view points to the slowdown of increases in health care expenditures and the enhancement of health care affordability and appropriateness for greater numbers of persons resulting from managed care cost-containment strategies and service review procedures. Mental or behavioral health care has been as strongly impacted as medical care under managed care. Where managed care has forced practitioners' attention to validated procedures and to examining previous wasteful practices, we ap plaud the movement. Where managed care has had adverse impact, we think there needs to be greater public, legal, and regulatory attention to its excesses and abuses.

Texte du rabat

This timely volume explains the pitfalls and problems of managed care for those practitioners, especially child clinicians, who wish to take part in it, while mapping out independent financing strategies for those who wish to remain outside the system. emManaging Managed Care/em provides an overview of the managed care marketplace as it currently affects children and families, reviews relevant legal and financial issues, and illustrates with case examples some problems of the system.

Contenu

1. Basics of Managed Care in Psychological Services for Children and Families.- Changes in Thinking about Health Care Reimbursement.- Changes Affecting Psychological Practices.- The ABCs of Managed Care.- Managed Behavioral Health Care.- Watching Managed Care Companies.- Conclusions.- 2. Problems Posed by Managed Care for Services to Children and Families.- Need for Child and Family Services.- Accessibility of Services.- Cost Containment and Utilization.- Quality of Care Issues.- Administrative Costs of Managed Care.- Accessing Services within a Managed Care Environment.- Current Procedural Terminology Codes.- Reduced Fees for Clinician-Providers.- Gatekeepers.- Utilization Management/Utilization Review.- Treatment Protocols.- Precertification.- Concurrent Review.- Denial of Service Authorization.- Restricting Patients' Access to Specialist Providers.- Medical Necessity and Noncovered Diagnoses.- What Drives Managed Care (and Drives Psychologists Elsewhere).- 3. Legal and Ethical Issues for the Clinician in Managed Care.- Restriction of Services.- Undertreatment.- Information Disclosure.- Liability and Hold Harmless Clauses.- Appealing Adverse Coverage Decisions.- Treatment beyond Reimbursement.- Confidentiality.- Managed Care Contracts.- Concluding Remarks.- 4. Adapting to the Managed Care Environment.- Accessing Provider Panels Generally.- Accessing Panels as a Specialist or Subspecialist.- Writing Behavioral and Measurable Treatment Goals.- Outcome Measurement and Evaluation.- Consumer Satisfaction.- Clinical Problems Not Covered by Managed Care Plans.- Prioritize Problems, Prioritize Treatments.- Using Time-Limited Therapy.- Office Overhead.- Helping Consumers Make Informed Choices.- Advocating for and with Consumers.- Changing the MentalHealth Care System.- Adapting to Managed Care.- 5. Limiting Negative Impact of Managed Care on a Clinical Child/Pediatric Psychology Practice.- Advantages and Disadvantages of Practicing in a Managed Care Environment.- DiversifyBalancing Sources of Managed Care Reimbursement.- Evaluating the Business, Protecting the Practice: Lethal Pitfalls to Avoid.- Handling Insurance Claims.- Marketing.- POS Option.- Group Practice.- Types of Groups.- Capitation.- Managed Care and the Clinician.- 6. Practicing outside Managed Care.- Advantages to Fee-for-Service Clients.- Identifying and Recruiting Self-Pay (Fee-for-Service) Clientele.- Financing and Payment Options.- Goals/Standards for Practice as a Business Setting.- Marketing.- Accessibility.- Diversifying Referral Sources.- Working in Primary Care.- 7. Scientific Bases for Clinical Practice in Managed Care.- Do Psychological Treatments Work?.- Fitting the Pan to the Ham.- Medical Cost Offsets for Treatment of Children and Families.- Treatment Acceptability Findings.- Consumer Satisfaction Findings.- Referral Source Satisfaction.- Documenting What the Psychologist Does in Practice.- Epilogue.- References.