Access and Utilization of New Antidepressant and Antipsychotic Medications. E. The Changing Role of Managed Care


Resistance to managed care has centered on the restriction of patients' choice of plan and provider; on plans' denial of services or reimbursement; and on plans' continual reduction of provider reimbursement rates. Both Congress and most state legislatures continue to consider Patients' Bill of Rights legislation as a way to ensure some level of quality of care. The President's Commission on Consumer Protection and Quality drafted a bill of rights in 1997, which has been mandated for all Federal agencies administering or managing managed care programs, and the Administration has made Congressional enactment of a strong bill of rights a high legislative priority. While Congress rejected such legislation in the last session, they have responded to continuing public pressure by again introducing more limited bills, and some action may be taken leading up to the next election.

Mental health is a leading source of egregious examples of managed care "abuses." Plans are thought to use a highly restrictive definition of "medical necessity" to limit or deny mental health treatment, especially inpatient care. Choice of providers, access to specialty providers, and confidentiality are highly sensitive issues in mental health care, particularly for individuals with long-term or chronic conditions. Moreover, experienced specialty mental health providers -- particularly those accustomed to public sector grant funding -- have had difficulty adapting to managed care contracts and reimbursement structures. All of these concerns are subsumed within the "quality" and "patients' rights" issue.

At the same time, several managed care organizations have removed prior approval requirements designed to ascertain "medical necessity." These restrictions were usually applied to procedures and hospital inpatient admissions. However, in some cases pharmaceuticals are included in these regulations. It appears that managed care plans are beginning to adopt a less adversarial role in controlling utilization, moving instead to a role of physician education and assuring quality.

Managed care has contributed significantly to reducing mental health's share of the premium dollar (in private insurance) as well as to a fundamental restructuring of the public system, with a similar loss of visibility and importance for mental health within state governments. As a result, the constituency has less clout in demanding quality. However, the constituency is very experienced in challenging the public care system, and would be active users of any grievance/appeal and litigation options that are enacted to protect managed care consumers.

Pharmaceuticals play into these issues in several ways. First, the mental health constituency demands the latest and best medications as a key element of quality. Second, new medications are recognized as a major factor in cost increases -- particularly in mental health (with a high incidence of new drugs available). The mental health constituency is very concerned that cost pressures (with the reduced premium share or funding for mental health) may encourage managed care plans to replace clinician time with medication. An increasing concern will be whether the costs of mental health medications come out of the shrinking mental health portion of the premium/capitation rate, or out of the overall health dollar.

It is not at all clear, however, that psychotherapeutics will be alone in terms of pressure to reduce costs. Psychotherapeutics are generally considered as one of five major pharmaceutical cost centers that also include anti-infectives, cardiovascular, gastro-intestinal, and analgesics. One may expect that as the population ages, most of these categories will encounter increasing pressure to control costs as the number of patients who are candidates for these drugs increases (especially cardiovascular and gastro-intestinal agents). Although cardiovascular and gastro-intestinal drugs are potentially capable of reducing the volume of expensive medical procedures (e.g., coronary artery bypass graft, percutaneous transluminal coronary angioplasty, or endoscopy), the effects of such shifts (should they occur) remain equally unclear.