The duration of an individual's enrollment in a managed care plan is highly variable. Several factors contribute to disenrollment, including consolidation and failure of health plans, employer-directed changes in health plans in order to obtain better value, enrollees' search for better drug benefits (1), psychiatric diagnosis (2,3), and overall dissatisfaction with the plan (4). When a person's health plan is replaced, there may be a sudden disruption to treatment if the enrollee's current behavioral health care provider is not part of the new provider network.
For behavioral health care in particular, disruption to treatment may have dire consequences. It threatens the therapeutic relationship (5), may result in some anxiety and insecurity on the part of the patient (6), and could even cause serious damage to the therapeutic process. Persons with mental illness are especially vulnerable. For example, one study showed that persons with symptoms of depression were less likely to disenroll from a health plan when they were dissatisfied than were enrollees with physical symptoms (2). A careful literature review found no further research addressing the transition of behavioral health care from one plan to another.
Presented here is a model that was used during the transition of 4,075 active commercial and Medicare enrollees from a large medical managed care organization (MCO) to an academic managed behavioral health care organization (MBHO). We present a best-practices model to guide the transition of behavioral health enrollees between plans.
In early 2000, AvMed Health Plan, the largest nonprofit MCO in Florida, awarded a full-risk capitation contract to University of Miami Behavioral Health to manage its South Florida mental health and substance abuse benefits for 186,634 commercial and Medicare covered lives. AvMed's statewide enrollment was 319,109 lives—covered by commercial insurance, point-of-service plans, Medicare, and Medicaid—of whom 58.5 percent were in South Florida (7).
University of Miami Behavioral Health is a division of the department of psychiatry and behavioral sciences of the University of Miami School of Medicine. It was established in 1993 as the managed behavioral health care carve-out for the faculty and staff of the University of Miami and their dependents (16,000 lives). Initially, the provider network comprised university faculty and community clinicians known to the university community. When planning began for the assumption of AvMed enrollees, the initial enrollee population had expanded to 40,000, and the provider network had increased to 100 licensed professionals. The ultimate expansion of services would increase enrollment by a factor of almost 5.
AvMed (the MCO) and University of Miami Behavioral Health (the MBHO) hoped to realize specific strategic advantages from the union. The MCO hoped to gain a high-quality delegate for behavioral health services and the prestige and recognition of the University of Miami in South Florida. Its primary concern was that the care of its enrollees not be disrupted. A measure of enrollee satisfaction would be the absence of telephone calls and complaints to AvMed's member services department during the 90-day transition of active enrollees. The academic MBHO was taking a calculated risk, because an expansion of five times its enrollee population would leave the organization vulnerable if full-risk capitation were not sufficient to cover utilization expenses. In addition, there would be a cultural shift from a small organization with a generous benefit plan and a provider network composed disproportionately of academic psychiatrists to a community-based network.
Implementation planning began on March 1, 2000, and the transition began on July 1, 2000.
The challenge facing both health care organizations was to plan the logistics of transferring ongoing treatment by identifying MCO enrollees who were in treatment, notifying their providers, and preparing both enrollees and providers for the change in behavioral health coverage. The MCO gave the MBHO an electronic list that was used to match active enrollees to providers inside and outside the MBHO network. The MBHO's network was expanded to include 95 percent of the MCO's providers in the case of geographic overlap between the two networks.
Thus MCO enrollees who were in active behavioral health treatment fell into two groups: those who were being treated by one of 75 providers who were already in the MBHO network, and those who were being treated by an MCO provider who was not in the MBHO network. The first group would make a smooth transition: providers were mailed a list of affected patients and were informed that after a given date they should request authorizations for continued care from the MBHO instead of from the MCO. Any benefit limits were transferred to the MBHO. For the second group, an innovative approach was required so that ongoing treatment would not be disrupted.
Identifying enrollees at risk of treatment disruption
Of the MCO's total enrollee population (186,634), 4,075 (2.2 percent) were receiving behavioral health services at the time of the transition—that is, they were active enrollees. These active enrollees and their providers were notified by mail 30 days before the planned transition date. A letter was sent to the providers in the MBHO network to inform them of the date on which they should begin to use an authorization process that was familiar to them. Providers who were not in the network received preemptive authorization for three visits to allow them to continue treatment before the assigned transition date and were invited to join the network. They received authorization for five visits if they joined. By the end of October 2000, 97.1 percent of the MCO's active enrollees were being treated by providers in the MBHO network.
Network development and relations
In the lexicon of managed care, benefit plans that have been sold to businesses (commercial plans) and defined populations—for example, Medicare and Medicaid—are referred to as product lines. Within the commercial product line, corporate groups of enrollees are called accounts. Because these accounts constitute a large proportion of its business, the MCO was understandably anxious to ensure that major accounts would experience minimal disruption to their employees' care. The MCO provided the MBHO with the name of a contact person for each major account that had an employee assistance program. Each employee assistance program prepared a list of 20 preferred providers who represented the bulk of its referrals. Directors of employee assistance programs were guaranteed that credentialing of their preferred providers would be a top priority and contingent on successful credentialing review and acceptance of the plan's fee schedule by the providers.
Any providers who were not in the MBHO network were extended single-case privileges until they were processed through an expedited credentialing review. Only two providers declined to join the MBHO network, because they deemed the fee structure to be unacceptable. These two providers were allowed three transition visits to either terminate care or transfer their clients to a provider in the MBHO network. At the time of the transition, 75 providers in both networks were treating 4,075 active clients. By the end of October, 98.8 percent of active enrollees were being treated by providers in the MBHO network.
Multiple satisfaction-related outcomes were clearly defined by both the MCO and the MBHO at the outset of the planning process. The goal for each of these constituencies was to complete the organizational transfer with minimal disruption to ongoing treatment.
Enrollee complaints and satisfaction
The MBHO received one complaint from an enrollee who was told by her provider that he was no longer permitted to treat her because he had not been invited to join the MBHO network. In fact, that provider had been invited to join but declined because of the new fee structure. The enrollee was informed and subsequently confronted her provider, terminated care with him, and chose another provider from the network. There was extensive and intensive communication with transferring patients, including explicit notification of complaint procedures. As a result, enrollees had few surprises about the process. The MCO received no complaints from enrollees.
Provider complaints and satisfaction
Providers were very satisfied with the transition process and experienced no disruption to their clinical practices. Neither the MCO nor the MBHO received any complaints from providers.
MCO complaints and satisfaction
Beginning four months before the initiation of the transition, group meetings were held routinely to identify organizational strengths, thus creating ownership at all levels of both organizations. Meetings were arranged with senior administrators of the MCO and the MBHO, marketing representatives, and representatives of major accounts to build trust and credibility. Having the opportunity to discuss their perceived needs allowed employers to "buy in" to the process and gave them a sense of control.
The result of this collaboration was a shared response to the identification and solution of problems, which in turn resulted in a high level of satisfaction on the part of the MCO as well as a shared sense of accomplishment. Furthermore, the MCO did not receive any complaints from its client employee assistance program or from its own member services department.
It has been suggested that disruption to care due to recent withdrawals of Medicaid managed care plans can be mitigated by overlap in local plans' provider networks and transition policies that affect enrollment (8). The experience we describe suggests that the same is true in behavioral health care. The relatively smooth transition of active enrollees should become the benchmark for all managed behavioral health care organizations.
Although spontaneous complaints from all stakeholders—patients, clinicians, employee assistance programs, health maintenance organizations, and so on—are an appropriate outcome measure for plan transitions, it is worth considering a more active approach to solicit such feedback. We hope that the extremely low rate of spontaneous complaints we received reflects our efforts toward a smooth transition. However, it is possible that if we had solicited complaints we would have received more of them. In the spirit of determining best practices, we recomend that future efforts in this area involve contacting and informing all stakeholders—ensuring anonymity when possible—and following up with anonymous satisfaction surveys.
Network integration and preemptive enrollee notification is contingent on the MCO's sharing the claims files of active enrollees with the MBHO. Unfortunately, such cooperation is unlikely without legislative intervention, because the outgoing MBHO has little or no incentive to assist the MBHO in the absence of an ongoing business relationship. At a minimum, there should be mandated contractual language and perhaps state statutes that require MCOs and MBHOs to provide active client data to new MBHOs at least 60 days before transition.
The authors are affiliated with University of Miami Behavioral Health. Dr. Brickman, Dr. LoPiccolo, and Dr. Eisdorfer are also with the department of psychiatry and behavioral sciences of the Miami School of Medicine. Send correspondence to Dr. Brickman at the Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine (M861), P.O. Box 016960, Miami, Florida 33101 (e-mail, firstname.lastname@example.org). William M. Glazer, M.D., is editor of this column.