CHAPTER 5: EXPLORATION OF A POSSIBLE COST-NEUTRALITY (VIS-A-VIS CURRENT PLANS) IN A POINT OF SERVICE TRIPLE OPTION MANAGED CARE OUTPATIENT MENTAL HEALTH PLAN DESIGN

I. Problem formulation

I have found myself increasingly thinking about how it might be possible to repair some of the losses reported. To that end, I have developed what I call a point of service triple option (POSTO) managed care outpatient psychotherapy plan design. This design was discussed in detail in Chapter 4.

Since the current health care financial climate is tight (see Chapters 1 and 2), any new plan design's cost effectiveness and, if possible, cost-neutrality needs to be high priority during anyone’s design process. Although this need for cost-control compounds the problems involved in addressing and ameliorating the four losses, in general in social reality people defend stubbornly against change, even helpful change that costs more money than they are used to paying. Sad but true, without reasonable neutrality in cost, decision-affecters and decision-makers may shelve any such idea, no matter how healing for consumers and clinicians. "It's a good plan, but we can't afford it," they might say.

If POSTO design in outpatient mental health care can be shown to be reasonably cost-neutral in the potential redesign of existing managed care outpatient mental health plans, then, without the diversion of significant cost differences, stakeholder decision-affecters and decision-makers can be freed to compare the service delivery issues, alternatives, and opportunities on their own merits.

Fortunately, I believe that reasonable cost-neutrality in per-outpatient-therapy-visit costs can be modeled, developed, and provided. To do it, the plan designers would need to find an appropriate combination of the following: clinical provider per visit discounts, clinical provider covered visit maximum charges (often called "caps"), consumer co-pays, and health plan benefit payment levels to clinical service provider or (in the case of a consumer's choice of outpatient psychotherapy treatment through Option 3) consumer. In this dissertation, design factors, data, and calculations provide foundations for further development of such a model. This model could be of use in stakeholder work toward the provision of adequate covered outpatient psychotherapy through managed care health plans in the U.S.

II. Design and justification

In this chapter, I focus on the mathematics involved in exploring what balance of per-visit discounts, visit payment maximum caps, consumer co-pays, and health plan payments it would take to establish a reasonable per-therapy-outpatient-visit cost-neutrality within the plan no matter which of the three allowed Options for choosing outpatient psychotherapist service the consumer picks.

If one can rebalance and broaden offerings and combinations of choice a health plan provides in these ways without needing to increase the plan's premium price, one can say that reasonable cost-neutrality has been achieved. I have designed a three-option outpatient mental health plan. In this chapter, I develop a hypothetical calculation of the cost of each of the three Options for treatment visits. These costs are based on my hypothetical assignment of what I believe to be reasonable discounts, co-pays, and payments by clinician, consumer, and health plan in each of the three Options, plus caps on clinician fees charged. In each case, I note the basis on which I chose each mathematical element. My goal in this study is that, if possible, once each of these elements is joined together, these calculations show the same per visit cost whether the plan participant consumer chooses to get outpatient therapy using Option 1, Option 2, or Option 3.

After looking at background and justifying each component of the calculation to come, this Chapter calculates outpatient-per-visit costs in comparison to each other (for each of the three plan options for service) at common hourly rates outpatient psychotherapists charge in this area, Sonoma County in Northern California.

Ms. Chris Alesso, Assistant Director of Underwriting for California, Kaiser Permanente Health Plan, was an independent pro-bono consultant to this report. She has done her own study, cognizant of my research at present, and produced her own independent underwriting comparison of the cost-neutrality of the per-visit costs among the three Options which I present in the point of service triple option (Alesso, 1999). Her report is provided as an Appendix.

III. Assumptions about hypothetical models of health plans involved in the study

The calculations involved in this presentation are all based on the premise that a hypothetical large Sonoma County public jurisdiction organization establishes a hypothetical (and so far, with one exception, only an idealized system design) POSTO managed care outpatient mental health plan, as roughly described in this chapter and elsewhere in the dissertation.

This chapter's calculation is about relative costs within a single health plan, an inner-plan calculation. (Notes about cost-neutrality are provided near the end of this chapter and in the Appendix 1 comparing costs between this hypothetical plan and another closed-panel hypothetical plan with similar benefits to this plan's Option 1, to see if this plan design can not only be internally cost-neutral but also suggests hypothetically the capacity to be reasonably cost-neutral in the current outpatient psychotherapy plan marketplace.)

Further, this chapter assumes in the discussions and calculations to come that the hypothetical outpatient psychotherapy benefit is considered a constituent part of the hypothetical HMO health plan which holds it, whether or not the benefit is held and operated internally by health plan administration, or whether the outpatient psychotherapy benefit has been ceded for direction and operation to constituent medical groups on a capitation basis, or ceded to a mental health "carve out" plan, in which the HMO contracts the mental health benefits out to an entirely separate managed care mental health provider organization (MCO). (In the latter two cases, the constituent medical groups or external MCO take all responsibilities for providing mental health benefits and administration, in return for a fixed capitated fee or a part of health care premium.)

A POSTO outpatient mental health plan past example found in the field: Dr. Nick Cummings' model at American Biodyne

Some years ago, for a coalition of several school districts fashioning a POSTO multi-jurisdiction health plan, I facilitated stakeholder negotiators from the leaders of labor and management of the different districts. They sat together at regular meetings for over a year at a common table developing their recommendations for benefit levels of the multi-district plan’s outpatient psychotherapy benefits. Although that plan has run for some years, claims experience records were not kept by the HMO, which was acquired by another HMO, so claims experience cannot be entered here.

I looked around the country for any other POSTO outpatient mental health plans I could find. Throughout my study of the literature on aspects of the crisis leading to this subject, I looked in a number of ways to find any trace of an already existing point of service triple option managed care mental health plan, which was technically what my plan design was shaping into. I couldn't find one. I thought if I could find POSTO mental health plans elsewhere or research reports of their activity and results, I could fine-tune my abstract design and mathematics. I then called pertinent institutes around the country to ask them. Nothing. I finally began to assume that mine was the only POSTO managed care mental health plan model designed or tried.

As a last check, I called a dozen national experts on managed care mental health around the country. The first eleven didn't know of any existing or past POSTO outpatient mental health models. The last I called was Dr. Nick Cummings, former President of the American Psychological Association, former CEO of American Biodyne, former director of the mental health program for Kaiser-Permanente, Oakland CA, in which capacity he became a major researcher and writer of 20-year studies in mental health at Kaiser. I found in talking to him that he had himself run a point of service triple option managed care mental health plan for 1/2 million people through his company, American Biodyne, during the late 1980s, until 1992, when he and his company were bought out. He reported that the plan worked successfully and was financially stable, without any significant cost inflation. He said that he made a point of offering about 60 free mental health education classes and stress reduction services which were widely used.

.Unfortunately, although the buyers insisted they would keep the plan running, within a year they put other business values into operation and closed this successful model plan, the success of which could have influenced later plan design.

As far as I can find out from substantial on-line searches and dozens of phone calls around the country, Cummings' plan and mine were the only POSTO managed care mental health plans to have been tried. Cummings believes that his POSTO managed care mental health plan was a success on both humane and cost-effectiveness criteria (personal communication, 1998).

Cummings (1988, 1997) would not consider a health system as comprehensive or economically efficient without mental health services. The amount of medical cost offset derived, however, is dependent not only on access, he believes, but also on the relative efficiency or inefficiency of the behavioral care interventions used.

He believes that this is why there is a wide variation in the amount of medical cost offset even with ready access. According to Cummings, focused and targeted interventions are both the most efficient (yield the highest cost savings) and the most effective (therapeutic gain to the patient). He sees the next generation of research demonstrating, measuring, and defining both access and efficiency as characteristics of a viable and comprehensive health plan. He believes the potential is enormous. He notes that a medical cost offset of only 6% in the $1.25 trillion annual healthcare expenditures would exceed the entire annual mental health/substance abuse budget of the United States (Cummings, 1997, pp. 19-20).

IV. Designing a point of service triple option (POSTO) managed care mental health plan to seek reasonable inner-plan premium cost neutrality among the three Options in the plan

Can we design a point of service managed care mental health plan and in so doing include a goal of reasonable inner cost-neutrality among the three optional ways of getting outpatient mental health treatment as a covered benefit under the health plan?

Here in brief are the three POSTO managed care outpatient psychotherapy choosing-of-clinician Options and then, as examples, their anticipated positive effects on the first two losses experienced by consumers and therapists.

Now, let us look at the effect of this POSTO managed care outpatient psychotherapy benefit on losses one and two described earlier in this paper.

Loss #1 stated that the consumer (patient/health plan participant) has experienced a diminishment or loss of the right to choose one's own therapist for outpatient psychotherapy. The array of three kinds of choice in the outpatient mental health POSTO opens the system up to allow the consumer to choose his or her therapist from among all licensed providers.

To allow the POSTO model to remain reasonably cost-neutral to the health plan, the consumer must pay more for the opportunity of going further outside the HMO system. In this way, the second Option (in hypothetical design a PPO panel which includes most outpatient clinicians in the geographical area) is calculated to allow approximately 50%-50% cost-sharing. In the model, the clinical provider has discounted retail fees by at least 20%, as a condition of participating in the PPO panel. The combination of the clinician discount and the plan payment comes to half the eligible visit charge, from the point of view of the maximum cap on eligible per visit charges. That is to say the eligible visit charge is the lower of the clinician's retail visit rate or the health plan's maximum cap on per visit rate, if the clinician's per retail visit rate is greater than the health plan's cap. The consumer pays the other half. In the third Option, the clinician does not choose to discount visit fees. Because the non-HMO/PPO clinician (clinical services usually referred to as indemnity or fee for service) has not lowered the per visit fee and because the health plan is holding its per visit payment constant, the consumer must pay an even larger part of the therapy visit bill.

Loss #2 described outpatient psychotherapy clinician experiencing diminishing or closed access to being reimbursed for treating the consumer through the consumer's health plan. In my POSTO managed care outpatient mental health plan model, clinicial providers in the area would learn that they have three potential ways to participate as clinical providers. A limited number of clinical providers negotiate with the health plan to form the HMO's closed panel and contract with the health plan at that level. If a local clinician does not choose to request to be on the small closed HMO outpatient psychotherapy panel (for a variety of reasons), he or she can still choose to participate in the HMO's contracted PPO (Option 2). This PPO panel also would include some peer-involved case management for those clinicians choosing to participate. Any local clinician who does not wish to be subject to HMO or PPO panel discounts and conditions would still be allowed to relate to the plan as a fee-for-services clinician, charging usual per visit rates. The reimbursement for fee-for-service treatment would be proportionately smaller in relation to the rate the clinician charges (and compared to the health plan payments under the first two Options of clinician participation in the POSTO). Reimbursements would be paid directly to the consumer once the clinician has filed the necessary paperwork with the health plan to prove appropriate clinician licensure and the occurrence of therapy visits with the plan participant consumer. By the POSTO design, all therapists are allowed to be in financial and contractual relationship to the hypothetical health plan in one of three Options, while the health plan's costs per visit remain the same at each of the three Options or, to put it another way, whichever Option the consumer plan participant chooses.

The point here is that all licensed clinicians would be re-enfranchised under this hypothetical POSTO design, in the sense that at least some (and an equal number of) health plan dollars would go to reducing consumer plan participant therapy visit costs.

If individual health plans were to take the initiative to adopt this design, clinicians would be re-enfranchised by those health plans participating in the model. If, on the other hand, state law were to be enacted requiring health plans to provide point of service or point of service triple option, then this re-enfranchisement would be for all covered health plans in the state.

V. Model for calculating managed care mental health POSTO costs and payments

The general model for this plan is expressed in Table 1.

Table 1

Hypothetical POSTO Managed Care Outpatient Psychotherapy Plan: Consumer Chooses Among All Licensed Outpatient Psychotherapy Clinicians Along the Following Model

Having established the outline above, I moved into consideration of the cost elements of each of the three key parties to the outpatient psychotherapy per visit cost: Clinician, consumer, and health plan.

Outpatient psychotherapy clinician cost, consumer cost, and cost to the health plan

The design goal here is to get the plan visit cost to be cost neutral, no matter which Option the plan participant selects. Each element of the cost (clinician discounting, consumer co-pay, or health plan payment) contributes to the total. I sought a balanced set among these elements which total 100% of costs.

I decided to check my assumptions about normal per outpatient therapy visit costs in Sonoma County, where I live, teach, and work. I found no studies published on per therapy visit costs in Sonoma County and no claims personnel there with sufficient records of market realities (since almost all covered therapy in Sonoma County is with two health plans both of whose outpatient therapy benefits are limited to small closed panels),

I went to primary Sonoma County and California organizations to get their perspectives. The respondents were as follows: J. Gordon, Ph.D., Executive Director, Redwood (Sonoma County) Psychological Association (RPA) (personal communication, February 5, 1999); D. Glick, M.D., Medical Director for Mental Health, Health Plan of the Redwoods (HPR) (an HMO with 90% of its business in Sonoma County) (personal communication, February 4, 1999); M. Haley, Ph.D., Executive Director, California Psychological Association (CPA) (personal communication, February 4, 1999); and P. Tice, Membership Services Director, California Association of Marriage and Family Therapists (CAMFT) (personal communication, February 4, 1999).

Table 2

Most common per outpatient therapy visit

rates in or near Sonoma County

From this information, I set maximum per visit price caps into the grid. I first built the grid step by step. Then I added the cost estimates. To make a conservative estimate of how per visit costs actually will be incurred, the calculations assumes that all per visit charges will be at the amount of the maximum cap, although it is likely that many charges will be below that, such as is indicated in Chart 2 above. (By so doing, it is anticipated that all money set aside for per visit costs and not needed can be set aside in a special reserve account. It is anticipated that these reserves can be used for any increases in visits and costs of administration, including costs for operating the affiliated PPO.)

Note that the maximum per visit price caps used in these calculations are not meant to be the only reasonable cap a health plan might set. They are meant simply to furnish a reasonable price cap level, based within a framework which reflects current practice costs in Sonoma County. This approach can show how a hypothetical health plan could achieve reasonably cost-neutral outcomes using maximum caps which Sonoma County’s current charges.

Elements down and across the experimental grid

Below are the grid elements I came to use. I will explain each, why I used it, and then take this grid through three calculations, based on three different levels of per visit cap. As noted, to be conservative, the calculations assume all per visit claims are at the maximum per visit charge permissible under the cap. The three different calculations show, on a per visit basis, and at a given dollar per visit hour cost maximum, whether the figures from the three Options show a cost-neutral balance. The calculations show the cost, income, and services for the three parties, clinician, consumer, and plan. The calculations show the discount to the therapy visit rate from the clinician, the costs to the plan for a plan participant to have an outpatient therapy visit at a certain consumer co-pay in each of the plan options. We can ask ourselves: Do the categories and calculations support the idea that the per visit charge to the health plan can be reasonably the same under each of the three POSTO managed care outpatient mental health plan Options?

For the purpose of this review of each of the elementsin the grid, I call the HMO panel choice Option #1, the PPO choice Option #2 , and the fee-for-service/indemnity choice Option #3.

Noted one by one, here below are the categories I use in the cost-neutrality calculations to come.

• Option (cost note to be under 1, 2, or 3)   #1   #2   #3

This allows each of the parties (consumer, clinician, and plan) to show how much they hypothetically contribute to cost in each of the three options.

• Test calculation at per visit fee cap ($70, $100, and $110 per clinical hour)

First, if we only did a single calculation of a single hourly rate, the process could include an anomalous element which could distort how results would more commonly come out. So the calculations tests three different maximum hourly rates hypothetically payable to a clinician for treatment visits.

Second, the variety of per visit fee caps given can show specific cost data depending on cap amount, based on the data shown in Chart 2, above. Generally, psychotherapy in Sonoma County averages out around $100 per visit, as noted by the respondents queried. If a plan designer wished to have a separate hourly rate cap for each degree level, the $70 level shows an example of a lower cost capped segment within a plan which might be providing a higher rate cap for Ph.D. and M.D. providers. It is from the starting place of the maximum per visit rate cap that the clinical provider discount to the health plan is shown.

• Clinical provider discount to health plan

I know from my health plan management, brokerage, and consulting experiences in the 1970s and early 1980s that prior to the managed care upheaval in the nation's health care system, clinicians normally did not discount their visit fees to their client's health plans. They mailed a bill for the therapy visits, and the health plan would respond with either necessary paperwork or payment. There were claims forms to be filled out, signed, and returned, plus periodic correspondence in the case of continued visits. In very prolonged cases, some case management might come into play.

But now it is common for clinical providers to discount their fees to managed care health plans to which they belong as providers. Therapists in private practice who are providers for HMOs may discount their fees by 40%. Those serving on PPO panels discount in the 20-30% range. (M. Haley, Ph.D., Executive Director, California Psychological Association, personal communication, February 4, 1999)

This category provides hypothetical discounts based on current market rates, shown in Chart 2, above.

• Consumer co-pay

In the days before managed care, consumers generally paid full rates for their outpatient psychotherapy services; from my experience with health plan study from 1970 until managed care began, health plans which had outpatient psychotherapy benefits generally had consumers pay 50% of the clinician's visit charges. Under managed care, in HMO care consumer per visit charges in outpatient mental health became most commonly modest flat fees, such as $5 to $35 per outpatient visit (Alesso, 1999; D. Glick, personal communication, February 1, 1999). PPO per visit charges have commonly been a percentage co-pay based on a PPO discounted clinician charge and are now becoming more commonly flat co-pays (M. Haley, personal communication, February 5, 1999). Now, in the POSTO model, consumers would have the choice among three different care options.

• Net remaining payment by health plan to balance of the clinician’s discounted fee balance

The results line shows the estimated cost for each of the plan's three options. If the internal cost-neutral calculations are in balance, the health plan's per visit cost for each option will be equal. Here is an example of estimated percentage payments and discounts to and from the parties.

Table 3

Visit Fees

Because medical providers and mental health providers are now commonly accustomed to providing health services to managed care plans at such discount levels (to HMOs at a 40% discount or more and to PPOs at a 20-30% discount) (M. Haley, personal communic-ation, February 5, 1999), I think it reasonable to presume they would provide services at these levels in this hypothetical model. Because psychotherapy consumers are now used to paying co-payments in the $25 to $35 range (D. Glick, personal communication, February 1, 1999; Ceci [last name withheld], Psychology Concepts, Santa Rosa, personal communication, February 5, 1999). I think it reasonable to presume they would pay this co-pay in this hypothetical model.

As noted in Chapter 2, a thumbnail "History...," Schwartz (1997), Schamess, (1996); and Hymowitz and Pollock (1995) report an over 80% market saturation of managed care closed mental health clinician panels. In Sonoma County, over 85% of consumer group plan participants are in two health plans (Health Plan of the Redwoods and Kaiser) both of which, as noted, have closed psychotherapist panels. This $50 is a significant per visit sum for most consumers. It appears to exceed the current normal plan-covered outpatient mental health visit co-pay range in Sonoma County. I know of no survey to confirm my assertion. However, I surmise that a number of Sonoma County consumers would be willing to pay 50% of the covered visit charge in return for the freedom to choose from a large PPO psychotherapist panel. I get this impression from the fact that the old pre-managed-care payment split was 50-50 and was a widely accepted social pattern. I think the willingness to share the cost evenly with the health plan will prevail if the mental health need is compelling and if one or more members of the broader PPO therapist panel are recommended highly by someone else whom the consumer trusts.

Reserving money in the outpatient psychotherapy budget for the potential scenario of moderately increased visits

A PPO (Option #2) can make quite significant consumer savings in the per visit charge because of the psychotherapist's per visit discount, and also because of case management. This discount savings is less than in the HMO but more than with indemnity outpatient visits. Because the number of visits must be kept under consideration as well as the price per visit, the health plan may wish to encourage proactive "peer" review to keep under consideration approaches to treatment chosen by consumer and clinician and the resulting number of visits.

Specifically to allow a reserve fund to pay for above average duration of therapy (number of visits), I suggest that some benefits to be offered contain a reserve against increased usage. First, the PPO clinician visit fee discount of 20% can be increased to a 30% fee discount during the POSTO's early periods, with the last 10% held in reserve for the year against potential increases in utilization costs. Second, since the maximum per visit fee cap being calculated in this study assumes that every visit is charged at the maximum cap, and since Chart 2 shows that many clinicians have normal visit charges significantly less than the maximum cap shown, the savings can be added to the same reserves for use to cover any additional visits beyond the current average. Third, because the Option 3 visits (called indemnity or fee for service) are with therapists who offer no discount to the plan and who may feel themselves least concerned with the health plan's successful operation, it may be a further conservatizing element to have the health plan at least consider some stair-stepping down of the health plan's Option 3 incentive payments to the consumer after a certain number of visits and before the covered payments run out altogether.

Hypothetical plan costs should in each case be calculated conservatively. Said another way, until there is significant plan experience to study, anticipated costs should be moderately overestimated in order to build and maintain a pool of money for additional claims.

Table 4

Outpatient psychotherapy clinician cost,
consumer (plan participant/patient/cost,
and cost to the health plan

Example #1, using a psychotherapist fee at a maximum cap of $70/hour

(All claims are assumed to be charged at the maximum allowable.)

Table 5

Outpatient psychotherapy clinician cost,
consumer (plan participant/patient/client) cost,
and cost to the health plan

Example #2, using a clinician retail rate maximum cap of $100/hour
(All claims are assumed to be charged at the maximum allowable.)

Table 6

Outpatient psychotherapy clinician cost,
consumer (plan participant/patient/client) cost,
and cost to the health plan

Example #3, using a clinician retail rate maximum cap of $110/hour
(All claims are assumed to be charged at the maximum allowable.)

Notes to the calculations:

As shown also in Alesso (1999, Appendix 1), the net remaining cost to the health plan hypothetically comes out even across the Options. Because the health plan's claims cost per visit is capped at the amount shown, the hypothetical system's model of per-visit cost-neutrality among three options is demonstrated.

A primary motivation for consumers in Option #1 is assumed to be lowest consumer cost per visit. This will be sufficient motivation for some that they will not be interested in the other two options.

A primary consumer motivation in Option #2 is having a wider list of psychotherapists from which to choose, in exchange for a higher co-payment. Many people prefer to choose their psychotherapist based on from friends, relatives, colleagues, or other professionals. If most psychotherapists in their geographical area use the PPO, consumers under Option 2 will be likely to be able to choose a particular psychotherapist. In any case, their choice of therapist has been expanded.

A primary motivation in Option #3 is to be able to choose any remaining licensed provider (and not be limited to a psychotherapist in the panels of Option #1 and Option #2). Although this entails higher cost per visit, it is still less costly than paying full professional fees. Furthermore, this Option, combined with Options 1 and 2, completes the plan's provision of consumers’ covered access to all licensed therapy providers. This can strengthen the consumer’s sense of being "empowered."

The plan's three Options are intended to be cost neutral for the plan and cost competitive. The neutrality is built into the POSTO by having the three Options with goals as follows:

Option 3 cost equal to or less than Option 2 cost;

Option 2 cost equal to or less than Option 1 cost;

Option 1 cost equal to or less than comparable closed plans.

When such an approach is carried out actuarially and in underwriting, a POSTO managed care outpatient mental health plan should be able to be developed having comparable costs to a closed-end plan in the same geographical area, etc. This perspective is shared and explained by Alesso (1999), as shown in Appendix 1.

Since the POSTO's Options 2 and 3 are designed to limit benefits so as to make the provider’s cost equal to or less than the POSTO's Option 1, this should allow the POSTO to be competitive with a closed panel plan offering benefits like the POSTO's Option 1. On a cost-containment level, the hypothetical POSTO is using maximum caps per visit in the calculation, and assuming all visits will be at the maximum charges (whereas a significant number of the visit charges are likely to be lower, as shown in Chart 2, above). The reserving process described above is to allow the plan to put money aside against increased administrative expense and possible increased average numbers of visits in Options 2 and 3. (Although I have not dealt with it in this dissertation, I am also interested in the how this dissertation’s ideas might also be adapted to a health plan’s co-payments for outpatient psychotherapy being highest in the early outpatient psychotherapy visits, such as up to the Federally qualified HMO mandate level, and then, as clinically necessary, continue beyond that at a more moderated level.

Given the reasonable hypothetical cost performance of the managed care outpatient mental health POSTO in this dissertation, it would be valuable to proceed to further testing. There is a need to reconfirm that the losses are being found in the actual marketplace. There is a need, if widespread losses are confirmed, to consider how serious the consequences are. There is a need to have leaders from different stakeholder perspectives consider how POSTO managed care outpatient mental health plan design might appear from the value priorities of their respective stakeholder groups. For these and other reasons, further focus groups made up of experts with backgrounds in the different stakeholder groups could constitute an useful next step in this study. Such further focus groups could consider the four losses, the potential application of a POSTO managed care outpatient psychotherapy plan design as one solution, and possible further principles on which to build.

Visit Appendix 1: Developing and costing a cost-neutral point of service triple option managed care outpatient mental health plan, by Chris Alesso

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