The rapid transformation of the public mental health delivery system into a system of public contracts for privately delivered care is the most important current trend in managed care. Done well, privatization could improve care for a vulnerable population and give taxpayers more value for money. Done poorly, privatization will be a public health disaster. If the recent past predicts the near-term future, both scenarios will occur (1).
Massachusetts, which has had the first Medicaid carve-out contract (since 1992) and the largest (with approximately 400,000 recipients), provides an important laboratory for studying privatization of public-sector care (2). This column describes a successful case management program for public-sector clients operated by the Massachusetts Behavioral Health Partnership, the carve-out provider in Massachusetts since July 1996. Future columns in this series will address other effective strategies in public-sector managed behavioral health care, including ways to link financial incentives to clinical processes and outcomes.
Because I try to devote these columns to positive lessons about how to make managed care work well, at a recent meeting of the Massachusetts Psychiatric Society I asked several colleagues who have extensive experience with Medicaid clients to tell me what the Massachusetts Behavioral Health Partnership does really well. All gave the same answer—the intensive clinical management program. Considering that the individuals I polled ranged from skeptical to hostile in their attitudes toward managed care, I took their answers as relevant indicators that the Partnership's intensive clinical management program is doing something right and might provide pointers for clinicians and public programs in other states.
"Case management," or "clinical management," is an ambiguous term that can refer to radically different activities ranging from expansive efforts to increase access to care through assertive community treatment to restrictive efforts to reduce expenditures through application of narrow definitions of "medical necessity" (3). Such efforts to increase access to care are primarily associated with the public sector, while restrictive efforts are primarily associated with the private sector. A truly successful carve-out case management program would be a hybrid that combined public-sector receptivity and asylum with hard nosed private-sector efficiency.
The intensive clinical management program, which was implemented in 1994 by the initial Massachusetts carve-out provider, Mental Health Management of America (4), is currently staffed by 17 full-time clinicians distributed across the state. They work with approximately 650 adult and child clients. The Massachusetts Behavioral Health Partnership intends to increase the enrollment by 100 during the next year.
Any one of the following criteria makes a client eligible for referral to the clinical management program. The criteria are intended as guidelines for referral and are not rigid hurdles that must be met.
• Resource utilization factors: 52 or more days of acute-level service during the preceding year
• Clinical risk factors: noncompliance with treatment or treatment failure during the past six months, catastrophic events, a newly diagnosed axis I disorder resulting in a first inpatient hospitalization, or use of alcohol or drugs during pregnancy
• Demographic factors: having other family members who are using services; increasing age ("aging out") of child clients who now need adult services; significant medical comorbidity; complex ethnic, linguistic or cultural factors; and serious illness coupled with responsibility for children under five.
The role of the intensive case management clinician is conceptualized as hands-on coordination, authorization, and monitoring of services under the insurance contract and advocacy for additional services with other agencies and the school system. The overarching goals of the program explicitly include both meaningful functional improvement— "improve the quality of life for this at risk population"—and effective resource use: "decrease the use of unnecessary acute inpatient services."
Program eligibility criteria are summarized from the program's initial intake and referral form. Program objectives are quoted from a program description entitled "Intensive Clinical Management Program and Pregnancy Enhanced Services." (Both documents are available from Nancy Lane, Ph.D., Chief Operating Officer, Massachusetts Behavioral Health Partnership, 150 Federal Street, Third Floor, Boston, Massachusetts 02110.)
Although the intensive clinical management program is not envisioned as a direct provider of services, successful establishment of a collaborative relationship with clients and families combined with creative treatment planning clearly involves the potential for significant ego-oriented support as well as the kind of "outside-of-the-box" clinical thinking the Massachusetts Behavioral Health Partnership hopes to foster. The company's approach is illustrated in the following (disguised) case examples.
A 20-year-old single woman, pregnant with her second child, had experienced multiple admissions for drug and alcohol detoxification before and during pregnancy. The clinical manager with the intensive clinical management program arranged for her admission to a detoxification facility with special services for pregnant women. Staff at the facility worked with the patient's resistance to using mental health and other services in the community and her fear that if she came to the attention of community agencies she would surely lose her children. The clinical manager authorized and the young woman accepted daily postdischarge help from a community support worker, who helped with housing and ensured the patient's attendance at a structured outpatient addiction program. The woman remained abstinent and gave birth to a healthy, full-term baby.
A 37-year-old woman with a long history of severe illness, recurrent suicide attempts, and frequent hospitalizations was doing so poorly that some of her treaters believed chronic institutionalization would be necessary. The worker with the intensive clinical management program convened a series of team meetings attended by more than ten providers who were involved in the patient's care. The group ultimately agreed that a regularly recurrent family stressor might be triggering the regressions. With the patient's agreement, the worker authorized weekly use of a crisis bed when the unavoidable family problem occurred. The patient's functioning improved substantially and—except for continued use of a crisis bed one day a week—she was not hospitalized for the next year.
Walking the walk versus talking the talk
Talk is easy and cheap. Care for the vulnerable population that receives public-sector mental health care is difficult and often costly. An excellent mission statement is necessary but not sufficient to produce an excellent program. Based on a series of interviews with a range of stakeholders in the intensive clinical management program, I believe it is possible to define some preliminary lessons about facilitating conditions that help to move case management objectives to realities in public-sector managed care.
There are at least five major reasons why a managed behavioral health care program providing services in the public sector should make a substantial investment in a program similar to the Massachusetts Behavioral Health Partnership's intensive clinical management program:
• First, and most important, seriously ill clients can, of course, frequently achieve substantial gains in functioning and fulfillment.
• In accord with the "80-20 rule," a small number of clients will account for a large proportion of cost. Applying well-documented effective methods (5) can often provide a good long-term return on the short- and medium-term investment (6).
• Besides engendering major costs, the population eligible for intensive clinical management is subject to multiple crises involving potentially avoidable disruptive behavior that can create havoc in the care system and political problems for the system.
• Given the widespread perception that managed care equals "1-800-just-say-no," demonstrating a serious commitment to the most impaired members of the population conveys an important message to clients and families, to providers in the network, and to the staff of the managed behavioral health care program itself.
• Public officials and legislators prepared to support high-quality mental health care encounter opposition from skeptics and fiscal conservatives. If they can point to a vigorous, effective program for the most seriously ill citizens, they will be more effective in the political process.
For clinicians who provide care in the network, obtaining intensive clinical management services for their patients can make a substantial difference in clinical course and outcome, because the clinical manager can authorize a wide range of community and intensive outpatient services. My interviews with network clinicians and clinical managers suggest two strategies that will help clinicians to obtain case management services for their patients.
The first is to have a clear understanding of the eligibility criteria and overall objectives of the program so that patients who may benefit from the services can be referred in a timely manner. In addition, a clear understanding of the criteria allows the clinician to make a referral that specifies how the patient meets those criteria and how the patient will benefit from the program, thereby increasing the likelihood of obtaining the services. The second strategy is to make a clinical formulation that emphasizes systemic factors—how the patient fits into a family (or other social group), how the family fits into the community, and how these social system factors can be supplemented or better managed in the service of functional improvement.
Public purchasers who contract with managed behavioral health care organizations for provision of services to Medicaid clients can also learn from the experience of the Massachusetts Behavioral Health Partnership's intensive clinical management program. Contracts that carefully link financial incentives with important clinical processes and measurable outcomes rather than with restrictions on service increase the likelihood that comprehensive services will actually be delivered to at-risk populations. A future column will address this topic further.
Finally, although Medicaid managed care for general health services has had relatively weak consumer participation (7), the National Alliance for the Mentally Ill (NAMI) has recently issued a report about public-sector managed behavioral health care (8). The highly critical NAMI report applies nine practical criteria for assessing clinical excellence that will surely be a major force in shaping public discussion, advocacy, and quality improvement with regard to the privatization process.
In the next few years, the trend of privatizing former public-sector care will certainly continue. Critiques like the one recently put forward by NAMI will be a crucial component of the effort to "get it right this time"—that is, to avoid the past disasters of unduly rapid deinstitutionalization without having adequate community programs in place.
Instituting an approach like the intensive clinical management program described here is not a panacea. The Massachusetts program currently involves slightly less than 1 percent of the patients served by the carve-out program. The population it serves, however, is the neediest, most complex and difficult, and most visible among Medicaid recipients. Caring for these patients well can set a tone of clinical responsibility that is much more persuasive than speeches or brochures, can bolster political support for mental health services, and can demonstrate to the public that people with serious impairments can be helped.
Because the patients served by this program are especially vulnerable to uncoordinated care and other failures to provide high-quality services, it is important that a program like intensive clinical management be used as a living radiograph of how the system is functioning and as a source of quality improvement activities. Intensive clinical management is often a kind of glue that holds together a fragmented system for fragmented clients who cannot do it for themselves. If managed care works well, an intensive clinical management program can also suggest ways of putting those fragments together in new ways that will serve patients better.
The author thanks Kelcey Buck, L.M.F.T., Nancy Lane, Ph.D., Angelo McClain, L.I.C.S.W., Belen Ortiz-Brito, L.C.S.W., Marie Pierson, R.N., and Sharon Singer, L.M.H.C., for helping him learn about the intensive clinical management program, and Eric Goplerud, Ph.D., for suggesting the value of using Massachusetts as a case study.
Dr. Sabin, editor of this column, is associate clinical professor of psychiatry at Harvard Medical School and codirector of the Center for Ethics in Managed Care of Harvard Pilgrim Health Care and Harvard Medical School. Address correspondence to him at Teaching Programs, Harvard Pilgrim Health Care, 126 Brookline Avenue, Suite 200, Boston, Massachusetts 02215; e-mail, Jim—Sabin@HPHC.org.