CHAPTER 6: FOUR LOSSES, THREE OPTIONS, & SIX RECOMMENDATIONS

Losses to covered consumers and therapists, options to facilitate loss repair, and recommendations to improve further plan design

This final chapter, Chapter 6, concerns itself with evidence about the reported four losses to consumers and clinicians in outpatient psychotherapy covered by health plans, about the three Options in a Point Of Service Triple Option plan design, and about six recommendations which emerged from discussions in an expert multi-stakeholder focus group discussion, recommendations which could improve further design.

Four losses

The four losses reported in the literature and described earlier in this manuscript are as follows:

1. Consumers are experiencing diminishment or loss of the right to choose one's own clinician for outpatient psychotherapy,

Outpatient psychotherapy clinicians are experiencing diminishing or closed access to the prospective covered consumer's health plan. (Thus, the therapist can expect no covered reimbursement for client treatment).

2. Consumers and clinicians are finding their rights diminished or lost when they seek to choose the nature and approach for their covered outpatient psychotherapy treatment process.

3. Both parties experience loss of the right to determine duration of covered treatment or even treatment at all..

The focus group assessment instrument for the first hour used a seven-point Likert scale with 1 meaning "consumers have not lost the right at all", 4 meaning "consumers have lost somewhat", and 7 meaning "consumers have lost their rights on this completely". The focus group participants gave average ratings as follows on the question of loss.:

Table 1A

DID LOSSES OCCUR?

When the votes of the two experts who missed the focus group meeting but met with me individually are included with those of the focus group, the figures are adjusted as follows:

Table 1B

DID LOSSES OCCUR?

On the participant assessment instrument used at the end of the first focus group hour, the second question about each of the four losses was this: "If you think [identifying the loss] has happened, do you consider this an important loss?"

Participant responses were as follows: The participant assessment instrument gave a seven-point scale with the number 1 defined as " This is not an important loss at all", 4 defined as "This is rather important", and 7 defined as "This is a very important loss".

Table 2A

IF LOSSES OCCURRED, WERE THEY IMPORTANT LOSSES?

Tallies below are of the focus group participants who were present.

(Question 4b had a typo on the question. Only two participants voted.)

When the votes of the two experts who could not attend the focus group meeting but who each attended an individual session the next week are added (on questions 1b, 2b, 3b, and 4b), the average figures adjusted are as follows.

Table 2B

IF LOSSES OCCURRED, WERE THEY IMPORTANT LOSSES?

The focus group during the second hour considered the potential for the POSTO plan design to ameliorate any of the four losses identified. The first hour had established that the focus group members believed that each of the four losses had occurred. Now, given that losses were judged to have occurred, might POSTO be able to help? The participant assessment instrument administered at the end of the second hour asked whether the POSTO plan design offered any advantage (or disadvantage) in dealing with each of the four losses.

Question #1: "If you think consumers have generally had their rights in their health plans to choose their own outpatient psychotherapist significantly diminished or lost over the last decade under managed care, do you think POSTO outpatient psychotherapy benefit design offers an advantage in addressing this problem?"

Table 3A

DOES POSTO OUTPATIENT PSYCHOTHERAPY BENEFIT DESIGN
OFFER AN ADVANTAGE (OR DISADVANTAGE) IN ADDRESSING
THIS PROBLEM?

The seven-point scale was defined this way: 1: "POSTO offers bad design disadvantage"; 4: "POSTO offers no design advantage"; 7: "POSTO offers very strong design advantage".

When the two votes from those not at the focus group meeting but in individual sessions are added, the figures are adjusted as follows:

Table 3B

DOES POSTO OUTPATIENT PSYCHOTHERAPY BENEFIT DESIGN
OFFER AN ADVANTAGE (OR DISADVANTAGE) IN ADDRESSING
THIS PROBLEM?

Please note that except for one individual vote of 4 (on Loss #4), all participant response to all four questions in the participant assessment instrument used at the end of the second hour were 5’s, 6’s, and 7’s, suggesting focus group confirmation that POSTO design, in the focus group’s opinion, offers advantages in addressing the problem of the losses stated and further confirmed.

Consideration of the expert collaboration in the focus group on possible recommendations for future outpatient psychotherapy plan design

During the third and final hour of the focus group meeting, participants were encouraged to use what they had considered in the first two hours of the meeting to stimulate consideration of their own emerging priorities toward needed development of humane employer, employee, health plan, and public policy to meet this crisis. Using this focus, the group functioned not only as an expert focus group, but, at the same time, also as a meeting of stakeholder speakers, and as an idealized system design group beginning to define an image of what aspects of plan design could help.

During the third hour, the group reached near-consensus (defined as a 6 point average or greater on a 7 point scale on their own six strongest recommendations (or priorities or foundations) for ameliorating the four losses in the future and for strengthening the quality of covered outpatient psychotherapy.

Toward the end of this third hour, participants were given a third participant assessment instrument (one which allowed them to enter their own emerging highest priority subjects and then assess each on a seven-point scale).

The six recommendations they agreed upon were these:

One: Stimulate consumer learning, especially around choosing an optimum therapist and around expectations for successful treatment - explore what personal, group, and community mental health means,

Two: Approach outpatient psychotherapy preventively and with lifecycle issues in mind - education on what environments and what learning can help prevent mental health problems or what can be worked with early in the problem cycle,

Three: Make mind-body connections - look at the whole person - observe how mental and body healings are complementary, interactive, and interlocked - (Group note: For consistency, it would also be logical for existing POSTO health plans to contain POSTO outpatient mental health benefits),

Four: Increase knowledge of cost and pay attention to it - including comparative cost for medical care when good mental health treatment is and is not covered or is offered,

Five: Develop agreements about how to assess quality of care for consumers and how to measure - providing assessment systems and regular assessments - Studying service providers needs to be included in its responsibility for providing effective treatment, and

Six: Consider and provide for the needs of special populations.

The members of the group then assessed the importance of each of the six categories, using the third participant assessment instrument. The group decided not to rank order the six priorities. Thus, the six categories below are each to be considered of equal priority.

Please keep in mind that a maximum possible rating is 7.

Table 4A

SIX PARTICIPANT RECOMMENDATIONS FOR THE FUTURE OF COVERED
OUTPATIENT PSYCHOTHERAPY PLAN DESIGN

When the two votes from those who had individual sessions are added, the figure average adjusts:

Table 4B

PARTICIPANT RECOMMENDATIONS ON SIX FOUNDATIONS

FOR THE FUTURE OF COVERED OUTPATIENT PSYCHOTHERAPY

Scores

Qualitative focus group transcript study

So far Chapter 6 has reported the results of the three Likert scales (also called participant assessment instruments) administered during the focus group and the following week for the two absent members. Chapter 6 now turns to a qualitative study of the transcript of the focus group meeting.

According to Stewart and Shasmdasani (1998), in the qualitative text study, sets of categorized materials "provide the basis for the development of a summary report."

I have grouped participant comments/additions/contributions under the categories of the research questions.

The expert focus group meeting went through three distinct discussion periods over the three-hour group meeting: The first concerned itself with the "four losses" to consumers and outpatient psychotherapy clinicians; the second concerned itself with whether POSTO plan design principles could be of help in easing the losses found; the third explored for near-consensus recommendations which might possibly emerge from the group in the third hour, given the first two hours of stimulus.

First hour: FOUR LOSSES

Cost crisis transition to managed care clarified

Referring to the financial background and imperatives in which the managed care mental health movement developed, one focus group participant said, in discussing an old pre-managed-care indemnity health plan:

Ten years ago I was dealing with health care costs as an employer. We got, one year, we got a bill [that] increased our [health plan premium] rate by 99%. No warning. No nothing. Just the bill. They just expected us to send them a check.

"...[W]hose pocket is that [99% increase] going into? I tried for four years to get an answer to that simple question and never got it.

"...health care costs were generally going up 25-30% a year in the late '80s and early '90's. Well, [in] the rest of the country['s economy], the inflation rate was going up 2.5-6%. Somebody [was] getting that money, [and I] could never [get] an answer. And I just got fed up....I think that both employers and consumers got fed up with this and said 'we're not going to pay for it'."

A second participant said: "...as a result of people getting fed up,...they began moving into managed care plans."

A third participant said:

Ten to twelve years ago, contracts with bargaining units and so forth were negotiated for salaries. And health care would go over here somewhere. [Health care costs] went up and you got back to a meeting and you would talk about it a lot....All of a sudden health care costs started going up a heck of a lot more than salaries were going up. And negotiations turned into dealing with "compensation" rather than just with "salaries" - health care was a part of that. And decisions were made by employees and the employer negotiations. What was going to do what?

The first-mentioned participant said further:

"...they began moving into managed care plans, not because managed care plans were better for people, I don't think [they were]; I think employers moved into it to save money, because managed care plans, by definition, would be able to do that...."

Over the last dozen years, the mass movement of health plans to managed care was highly stimulated by the seemingly out-of-control annual premium increases which had been coming year after year. As overall health plan practice changed, outpatient psychotherapy plan design came to incorporate managed care practice, first in changes in how psychiatric residential care was conducted and, then, when managed care’s often 30% savings on this category became a big economic success, into the outpatient sphere.

Outpatient psychotherapy practice in recent decades had been covered on group health plans and rather loosely monitored. Now, on many plans, very limiting plan parameters are in force. That gives rise to a query voiced at the focus group meeting:

"But is the level of equilibrium that's been achieved there a desirable one? Or have the economics of the issue, of the argument, become more important than the quality of health care, whether it's mental health or any other kind of health care that we're delivering to people in this country?"

Subject: Loss #1

Covered consumer loses rights in choosing therapist

One participant explained this sense of loss for the consumer from the point of view of how the consumer feels the loss: "The first loss...listed is the loss of the ability to choose whether you can go to your friend's doctor; because if your plan, if that person is not in your plan, and you have a managed care plan, you may not have that option. You may have to go to somebody else, in which case your anxiety is even greater because you're going to be sent [by your insurance company or HMO] to somebody you know nothing about."

The participants in the third hour placed this loss and need in the wider context of the need for substantially increased teaching of plan participants about how to choose a therapist and do mental health work, how to consider mental and physical health together, how to think about and prepare a lifecycle of mental health needs and opportunities.

Subject: Loss #2

Therapist loss of relationship to the consumer’s health plan

The literature reviewed in Chapter 2, working with the health plans that their potential patients have, showed a large mass of therapists reporting difficulties. This was consistent with the understandings expressed by expert focus group members.

One participant expected the marketplace through the employer and health plan would remove some therapists whose reputations were not as high as the others. Another countered that since these matters are so intimate, they are usually not talked about, let alone talked about with the employer. A third participant noted that it might be easier to talk to a union shop steward if there were problems or fears of self-disclosure.

One effect of the earlier growth of outpatient psychotherapy as a covered health plan benefit had been that the number of psychotherapists had grown substantially. Now managed care limitations on clinician access to the health plans have taken a toll. This loss was expressed by a number of the focus group’s participants.

One participant described cut off and deterioration as a case in point:

"I definitely believe this is true that [outpatient psychotherapists are] feeling cut off. And I think it's similar to any other profession...where there is an over-glut...

I know that, from psychotherapist friends, even the ones on the cheaper end, the social workers and the Masters in Family Therapy (MFT), a lot of them are saying even when they get a contract...the expectations of what they're supposed to do are at a way lower reimbursement level...And if they protest, there are 800 others coming right up behind them, so they don't have much leverage in terms of bargaining power with health plans because there is an oversupply.

Because it is such a "buyers’ market" (of outpatient mental health services) under managed care, clinicians feel much less ability to negotiate good terms and less chance in appeal. One participant had not heard before of the condition in some contracts that prevent clinicians from continuing to see the consumer after the plan-covered treatment hours are used, under the jurisdiction of claims examiners often looking only for "medical necessity".

The participant said:

Some of this stuff that you talk about in here about these contractual conditions sound outrageous...[a] provision they can't deal with the client after they've gone over the limit that the plan will allow. Very powerful. Some of these things sound terrible.

Another participant raised another way in which even therapists who are contracted with may be put at disadvantage:

One of my ex-employers reduced their reimbursement rate to $37.50 an hour where most of them had been giving at least $55-60. So it was take-it-or-leave-it $37.50 an hour if you want to stay on our panel. And so what they wound up with on this panel was mostly brand new ‘just got my [MFT] license’ [practitioners], and so it was a huge quality issue.

A participant brought up another way that therapists feel left out by some managed care mental health company practices:

The way they contract, they would just take the telephone book, mail at random to licensees...'Would you like to join our panel? If so, send proof of licensure, proof of malpractice" and that was how they were certified...to get on the panel....That is one side of the low budget way of doing it....So [managed care mental health done this 'low budget' way] has had an impact on quality.

One participant looked at therapists working without the health plans:

The [best] therapists have survived because people are willing to [self-pay]. The psychiatrists have survived because of medication management….And then those quality people...have simply reduced their lifestyles, reduced their practices, and are working most with professional people who can afford to pay.

Another participant tried to understand how the diminishment of covered therapy hours affects different schools of therapy: "With all the other kinds of therapists that practice therapy, what's the shortest in nature? If you're a Freudian psychologist, you're going to be in the worst shape, and if you're behavioral-cognitive you're not going to feel the crunch at the same level."

Subject: Loss #3

Both lose right to choose therapy mode

Likert Scale results:

Has this loss happened?

Average of rating: 4 loss has happened "somewhat" (for both the group present and the two absentees who did the assessment the next week,

A focus group participant said:

...in the medical world, no matter how good or bad they do a job of this, physicians and physical therapists and all the different health professions are expected, when they get a patient, to have some kind of treatment plan, with an outcome....If you had a broken arm, you're supposed to be able to have this much range of motion, or if you had a heart attack, you should get to the point where you can walk and talk and breathe at the same time. And in mental health...I don't know that consumers are educated enough to walk in the door, see a therapist, know this is the right kind of therapist, and have some kind of clear outline of what should I expect when I'm done...And that is very upsetting to me as a public health professional, that that whole world [of mental health treatment] is [so] mystique-y, mysterious.

Another participant replied that the complexity of outpatient psychotherapy went even beyond that analogy:

"It's a lot harder than how to set a broken arm, and how long it would take that arm to heal, and what kind of motion I should have after that happens."

A third participant explained that pharmacology is being substantially increased by HMOs and managed care mental health plans, producing a decreasing need for therapist hours, which further compounds the situation:

The shift has been to medical management. So if you looked at the place to document payoff, see, if you look at the percent of drug sales over this period, you know, say 15 year period, of all pharmaceuticals, what percent of them are now psychotropic "meds"? What you will see: the groups that are making money off this are the pharmaceutical firms…. I have seen the average length of stay [on residential care] drop from 15 days [average] to 3 1/2 days [average]....That's through ‘improvement’ in medication. So what you see is a much higher use of medication in management….

A participant added: "Of course that raises the next question of the last two years especially. The rise in pharmaceutical costs as a percentage of health plan costs is faster than everything."

Then the participant continued: "What percentage of the pharmaceutical increase [in health care in general] is psychotropic drugs? Because the patients are being treated with psychopharmacology now instead of cognitive care."

One concerned participant critiqued the whole direction: "What if it is less expensive [and more effective] to treat in another way without medication?" This question calls for substantial and independent study. There is a danger that plans can pay undue attention to "saving money," creating profits, and minimizing premium inflation for the marketplace, while not studying sufficiently the question of whether the apparent savings are real. It is even necessary to work collaboratively on how to define "real".

Subject: Loss #4

Both suffer loss of right to choose therapy duration

One participant said:

Mental health benefits have almost never been as generous as medical benefits. And they have always been, for years now, [commonly] 20 visits a year [maximum]. I think the issue is now that they don't even allow you the 20 visits. they allow you 3 or 5 or 7....That's probably very significant.

The participant then claimed lack of expertise: "Whether that means that there's a difference in ultimate outcome, I don't know."

Another participant took this further:

Actually, this was more clear-cut to me that the first three [losses], because I don't see it necessarily as a loss. ...There have always been restrictions, even on fee for service plans in the [mental health] area.

A third participant drew a firm limit: "The amount of time that's available has probably been cut back too far."

Others were concerned about contract provisions barring clinicians from continuing to see the patient after the managed care mental health plan says sessions are no longer covered because they are no longer "necessary."

One participant said: "There's some managed care companies [for which] that's part of their [contracting agreement with providers]. They do not allow therapists to ‘self-refer’ after they have completed their pre-authorized sessions."

Another participant said: "That's really disruptive of progress that there's no opportunity to continue when some breakthrough has just happened. I find that particular restriction quite serious."

Another participant responded:

But I like the idea of limits. I like the idea of the responsibility of patient and therapist in the beginning [saying]: ‘Look. This is how much time I can offer to you. Let's figure out what it is that you can hope to accomplish in that period of time. Rather than just going on for 8 visits or whatever it is and then say, OK. Health care plan says you're done now. So, go away.’ And that's what happens. You can establish some parameters and expectation at the onset....I think it puts people in a mind-set that's more amenable to effective treatment.

Another offered the term: "Managing expectations."

This set of limits led one participant to more perspective on another related phenomenon, the reports of increasing numbers of therapists leaving work with managed care mental health plan companies:

Therefore, that's why some providers have opted out of panels, where they feel they are put at medical-legal risk, i.e., OK, if I can't even choose to see them for free and I don't feel this patient is stable, then where does it put me? And that's where you find they have defected, because they felt that their own license is in compromise. So that does happen.

Hour 2: POINT OF SERVICE TRIPLE OPTION (POSTO)

Dissertation research questions: If focus group members believe that serious losses were and are occurring, do they think that a Point-of-Service Triple Option (POSTO) outpatient managed care mental health plan design may have ameliorative effects on the "losses"? If they think positively about the POSTO design, may it be feasible to offer such a design in the marketplace at a reasonably cost-neutral premium to the employer?

Likert scale answers were high, indicating that he focus group scored POSTO design potentially able to help.

Table 5

POSTO: Help with the losses?

Note that Chapter 5 and Appendix 1 developed substantial evidence that POSTO would be feasible.

Participants further refined what their scores meant in the following comments:

They saw a need "for consistency among health plans which use Point of Service on their health benefits side, but ignore Point of Service for covered outpatient mental health needs: Does it make sense to me when a triple option point of service is offered for medical but not behavioral health? That… doesn't make sense to me....That doesn't compute with me.

Exploring this, another said: "I don't see how you can offer POSTO for medical, major medical and also not offer it for behavioral health. And so it’s the integration of the two that I think is critical." This became part of the recommendations.

Another made a prediction:

I do know that [freedom of choice in choice of therapist] was an important bargaining issue with the Teamsters when they chose their behavioral health provider...I think in the marketplace that what we're going to see is the [POSTO]… market driven by those whose insurers [will] use benefits to attract workers in a labor shortage..., by those who are after a niche in the market place and want some business where benefits make a difference. [For example] I'm thinking [about the use of outpatient mental health POSTO] probably [in] the computer industry, where you have a true labor shortage…

Another participant raised one of the particularly complex issues: considering workable pricing [and economic implications] for health plan, clinician, and employee under a POSTO outpatient mental health plan.

"Cost neutral for whom?" asked a participant. "All the stuff that's being added on, what you're proposing is all picked up by the consumer. So it's not cost neutral for the consumer. It's not cost neutral, it's not income neutral for the therapist. It's cost neutral for the employer."

The participant was referring to the fact that if the covered consumer chooses to get outpatient mental health treatment outside of the HMO-like setting (where covered consumer co-pay is assumed to stay relatively the same as now), the consumer’s co-pay increases. This is true and is a limitation of the POSTO method as applied here. Unfortunately, the capacity to choose alternative routes for outpatient mental health treatment is limited in this design to those who can afford the larger covered consumer co-pays. Low-income participants usually feel they cannot afford therapy without almost all cost being paid by the health plan. Their income and expenses reemphasize how little they have to afford large "out of pocket" costs for care in option #3 and even option #2. This disparity between rich and poor is beyond the scope of this dissertation but is a tragedy for many reasons.

One option, brought up by one of the group’s participants, was to encourage the parties to consider insuring together a large enough part of the risk to make POSTO co-pays affordable for the lower income covered workers and family members.

Perhaps the crucial tradeoff - the part that makes the POSTO change worth considering - is that, under POSTO, all licensed therapists become available to the consumer for some level of coverage. From the health plan-covered consumer’s point of view, currently the consumer commonly has mental health benefits available only from a very limited list of therapist panelists. In essence, under POSTO, in addition to the existing highly limited panel, the consumer would also have access to a large pool of licensed psychotherapists, as well as some subsidy in seeing any licensed clinician not part of any included panel.

From the point of view of any licensed therapist, and given that the therapist would be eligible to participate in one of the three Options for covered outpatient treatment benefits, most or all employees walking in the door would be able to allow the chosen therapist to be eligible for some level of reimbursement from the health plan. Note that the level of health plan payments to the therapist increase if he/she participates in the PPO (or HMO) level of the plan.

A critically important coincidence has emerged, one definitely worth mentioning. During those recent decades which were still pre-managed-care, large employer’s health plan outpatient mental health design generally called for a 50%-50% health plan-employee cost sharing of outpatient psychotherapy visit fee. In comparison, the outpatient mental health care POSTO as explored in this dissertation estimates an approximately 50%-50% PPO outpatient therapy fee-cost-sharing between health plan and covered consumer.

Note that consumers would be getting to choose from a large pool of outpatient psychotherapists who participate in a large PPO affiliated with the overall health plan. (Note that if outpatient therapists became part of the affiliated PPO, they would be agreeing to discount their normal charges for services through the PPO by a reasonable percentage, thus aiding in moderating plan and consumer costs.)

To a certain extent, through a PPO, this parallel offers a rather equitable bridge to build between the old covered outpatient psychotherapy treatment culture that has been lost and the new. For the large public struggle over the design and operation of covered outpatient therapy benefits to move toward resolution, the parties need to agree on the design of an equitable method of offering outpatient psychotherapy benefits. There is a nostalgia for the good old days of outpatient care. A new 50%-50% formula, albeit in managed care, might be able to help move discussion forward.

One participant concluded: "With the skilled labor shortage, we're getting back to where we were a few years ago, where you attract employees based on the benefit package. That's my sense of where [POSTO outpatient mental health] might go and where it might fit."

At the end, one participant hoped: "…[now] I think there’s a whole new reality out there….and eventually we’re going to get back to an equilibrium, where things are less than they were before, more than they are now, where there’s a balance…"

Hour 3: SIX RECOMMENDATIONS

Research question posed to focus group: If all of the answers are yes, are there principles to bear especially in mind, if such a covered outpatient mental health plan policy and system were to be developed?

The largest and most pleasant surprise for me in this research came in this last finding, the six recommendations made by the focus group. I had allocated the third hour, the last of the focus group’s three hours, to the possibility that the experts sitting together as a focus group could bring out and find consensus within the group on perhaps one or more recommendations which readers of this study could use to guide further study of covered outpatient psychotherapy plan design.

The focus group developed, proposed, and reached near-consensus on each of the half-dozen recommendations which emerged in their discussions. I call these near-consensus agreements "recommendations". Please consider the scores shown in Table E.

Table 6

Six Recommendations

Clearly, the group believed strongly that their six recommendations were important, both because of the high scores and also because of the near-consensus.

Recommendation #1: Consumer learning

How, the group asked, can a consumer get prepared to choose a psychotherapist? This led to the first near-consensus point about future work expressed in the focus group third hour: "stimulate consumer learning" about the goals of therapy, critical points in the lifecycle, and how to successfully pick and work with a therapist. With the scale end point 7 meaning "very important," this recommendation on stimulating consumer learning was rated 6.6. With an adjustment to include the two with individual appointments, the adjusted score is 6.14.

One participant said: "I don't go to my insurance and say 'I need thirty hours of Gestalt therapy.’ I don't know that. I don't know what I need."

Another participant described the predicament: ...people are pretty uneducated about it, even more so than physical health. And that is a shortcoming of the mental health profession, that I don't think people know what they're buying and what to be asking for.

Another participant said: "And I realized how big a gap in knowledge there still is about the disease concept and mental illness and medical models that affect it. People don't know that much about it."

Another said:

[A] continuum that runs between art and science is [this]: Are mental health professionals at the point where they know enough to give us as consumers that information so that we can make intelligent [decisions]? I get the impression that we still have so much to learn about mental health [problems] and how to treat [them].

Another wondered:

Do patients, do consumers know enough about the treatment, treatment alternatives, what they have, where they are, and where they can go, to make intelligent decisions? [This] is the question we've asked in a number of different occasions.... I think people have to be educated.... So whatever program we use, it's got to have a strong education component so people can make wise choices and can weigh money against alternatives...

Recommendation #2: Education: Preventive and lifecycle

Recommendation #2, on approaching mental health care preventively and in light of the lifecycle, was rated 6, adjusted to 5.86.

This builds on and is complementary to Recommendation #1.

One participant said:

The next...that came up for me was the whole concept of prevention....What's the parallel of health promotion for mental health, in the school system or wherever? Parenting classes, if you're starting with kids getting a good upbringing, all the way to, as a little kid, understanding the concept … what I'm just learning now, what are your core beliefs? What drives you? What is healthy at each stage of life? I don't think it's out there in a very logical, systematic way. So I started to sketch the equivalent of our life cycle stuff that we used to do for physical health as to what we wished for, inside schools, inside businesses. Is there a whole parallel world called [something like] Health Promotion-Mental that would cut the costs [of medical care] and do all the stuff we were trying for under physical health? ...[I]n a cost cutting world, and trying to do more for less, without that piece we're always going to be chasing ourselves.

Another participant said:

…in terms of prevention, in what our expectations are for ourselves and our children, healthy body-healthy mind go together and have always gone together in all of the work that was done in human population lab studies..."[S]ocial support has turned out to be one of the major determinings of how healthy you'll be both mentally and physically in almost any stage of your life....There are nuts-and-bolts issues of how to design a better service-delivery system within the budgetary constraints, and I agree to identify this as being one of the major 'drivers'.

Another participant encouraged us to study "where along the continuum of health any of us fall" and explore this as a study method with covered consumers.

One participant, thinking about health education approaches, defined a basis for considering someone mental healthy: "It’s the ability to function well in whatever environment you’re in."

A participant worked on seeing a process to develop:

A preventive approach to mental health. [I think of a] sort of public health set in me about mental health.... a subset of that would be defining at each stage what you need to be the most healthy, ‘cause that's going to change as you start to age.

Erik Erikson’s work was noted in this regard.

Another participant said: "I guess this links what you need to be mentally healthy at different stages of life. I can give you examples right now...just knowing what can give [inspiration] to school age kids to...express yourself, the wholeness of what a five year old should be able to do developmentally in a mental health thing to what a teenager gets to be able to do with peer pressure, and that comes with a combination of allergy stuff and there's a thought process they're cognitive developmental. And as you're an elderly person, issues of loneliness and depression and something that understands that you're in a particular stage of your life and what are the coping tools to deal with mental health issues of being."

Recommendation #3: Mind-body treatment

Recommendation #3, making the mind-body connections, was rated 6.8, adjusted to 6.57. (See Appendix 2, "Medical cost offset. Comments on the next research needed")

One participant said: "A lot of the problems we're seeing in mental health (managed care mental health services in general) are still a result of the fact of the separation [made] between physical and mental health."

Another advocated: "I think that we need to continue pushing parity issues in terms of benefit design...."

A third said:

The whole issue [has] skimmed all the research on stress vs. medical ailment, stress vs. mental health....We talk about it in front of the school district, in the cities. What part of what's going on for you is what? Child in stress? It erupts into a physical ailment....So, issues of lifestyle management, stress management, all those things are your 'bridge,’ because there's so much research out there between attitude, mental health, physical health, and managed life...lifecycle.

Another expressed a struggle: "I guess what I'm having trouble with is taking the language of physical health and making it completely translatable to mental health."

A participant saw focusing on ‘health as a whole.’ "That is a very high priority...not to artificially separate."

Another emphasized the need for a "better knowledge" of the question: "What is the cost of mental health, or the lapse of mental health, on physical health? Because once we know that better, we can substantiate why we're spending more on it."

Recommendation #4: Increase medical cost knowledge, including with and without good mental health treatment

Recommendation #4, to increase cost knowledge, was rated a 6.4, adjusted to 6.14.

One participant said:

Whatever plan design you need to come up [with] needs to accommodate those biologically based diseases - and epilepsy/anorexia in adolescence. We know from years ago that those are the most traumatic [and are capable of yielding] the biggest pay[back]....They cost the most but they may save the most. You have to take a longer view.

Another participant said how important it was that health plans become more acutely aware of the biologically based illnesses and more aware of the more chronic physical illnesses that need psychological and behavioral help: "I think the cost [of not providing behavioral health is] a critical public health need."

Recommendation#5: Increase quality assurance – including the role of providers

Recommendation #5, increasing study of quality of care for consumers, was rated 6.8, adjusted to 6.43.

Note that this was the highest score of the study.

One participant said:

Clearly the Department of Corporations in California has done a less-than-stellar job, and not surprising because they don't have any expertise in how to do it...[You would] think that by now, twenty years [of experience] later, they could have gotten some.

But, nevertheless, if you were going to [develop] a public policy position, what you really need is to develop a safeguard [system for when] what's out there in the marketplace doesn't 'hack it". You'd have to show that your credentialing process was not from the yellow pages. And you'd need somehow to fund this. Usually it comes out of licensing fees [of the health plans] today. But that's something that I would really feel would be important to try.

The participant then continued:

But even at an in-plan or a relationship-with-purchasing level, what are the administrative and managerial tools that are appropriate [by means of which] you can show what are your goals, what are you measuring against? Are you getting what you thought you were paying [for]? As well as at the individual level?…It's between the plan and the purchaser as well....to measure quality assurance. Quality assurance is measuring what you think you were getting versus what you actually got."

From a "public point of view" said another participant, those in charge need to "make sure at least structurally [that] plans are providing some mental health, [that] mental health services are operating appropriately."

One participant brought to the group’s attention a functionality scoring device in use, the "’GAF - General Assessment of Functioning’....There actually is such a thing as a GAF score that is measured in treatment plans - that's what's measured as the level of functioning."

Another tried an imaginary scoring: "I didn't come to work late once this week, as opposed to being out four times."

Another participant said:

I guess accountability and responsibility on the part of service providers. ...I think those things are necessary and that's what people should be looking at when they're competing, when they're going out to bid on those sorts of things. And I think it's the responsibility of the providers to be able to say: 'Hey, this is what I can do for you.’

Recommendation #6: Consider and provide for needs of special populations

Recommendation #6, considering and providing for the needs of special populations, was rated 6, adjusted to 6.17.

One participant said it was necessary "to be culturally sensitive" to the norms of the enumerable cultures we are close to, from Italian cultural norms to Latino cultural norms, from Sikh to Hmong, for instance. Participants noted differences in the needs of a wide variety of cultures represented in Northern California. One participant noted that over 80 languages are spoken in the Oakland public schools and over 120 languages are spoken in the San Francisco schools. A question was raised about how many distinct cultures that may represent.

One participant noted that

Some cultures have a higher level of acceptance of what others would call dysfunction. So there's a cultural definition of what is functional vs. dysfunctional. [Look at] assessment variations by culture in a "GAF" score. Level of perceived function cannot be done accurately and completely outside of the context of the person’s culture or cultures.

One participant focused on the importance of

the definition of being healthy in that culture, mentally healthy in that culture, working well within that culture, functioning within that culture. It may be very different what that means, what that looks like from the outside. It may be very different - first values, and standards, and aging."

Finally, one participant noted: "And I'm particularly concerned about special populations - for whom the more 'quicky' kind of approach is clearly not appropriate."

Results

Over the last dozen years, managed care methods have "saved" plans money. It is still not possible to quantify and balance all savings and losses. But according to evidence presented here, one unintended side effect in covered outpatient mental health treatment has been the widespread reporting of four serious losses in the way outpatient therapy is being provided by outpatient therapists for the covered consumers they see.

Since the four losses are important and serious, the primary stakeholder groups involved should consider ameliorative study and action.

This dissertation has studied the possible application of a POSTO plan design to help in ameliorative activity. Its potential cost-neutrality feasibility has been presented and supported. The expert focus group and the literature studied proved consistently encouraging exploration of Point of Service Triple Option plans as a way to help.

As this dissertation draws to a close, it is useful to review the discussion of the future of HMOs by Walter Zelman (1998). Zelman, a former senior Clinton health policy analyst and instructor in health policy and management at the School of Public Health at Harvard University, and now Executive Director of California’s primary HMO health plan alliance:

As managed care approaches the end of the twentieth century the preferred [health care] product appears to be a hybrid plan – essentially an IPA-type HMO, with a wide choice of individual physicians or groups, that still offers a point-of-service relief valve.

This dissertation has suggested how and why the same principle may be extended from the general HMO health plan and applied to the health plan component covering outpatient psychotherapy.

Four important losses in coverage have been incurred by consumers and outpatient psychotherapy clinicians who serve them. It appears feasible that a point of service triple option (POSTO) plan design could serve to ameliorate some of those losses.

The focus group agreed on six humane recommendations which they offered to help guide plan design.

Answering the study's research questions

Here are the answers the evidence suggests to the questions raised by this study.

I. Will a meeting of experts from primary stakeholder groups concerned with the provision of covered outpatient mental health treatment (unions, management, health plans, employers, health consultants, etc.) perceive in common that, from their own spheres of knowledge, these losses actually have taken place?

Yes, they believed these losses were taking place "somewhat."

II. If they believe the losses have taken place, how serious do they think those four losses are?

The focus group believed them to be "rather significant," and comments explained their views.

III. If they believe that serious losses were and are occurring, do they think that a Point-of-Service Triple Option (POSTO) outpatient managed care mental health plan design may have ameliorative effects on the "losses"?

In their voting reported earlier in the chapter, they rated the potential ameliorative role of the POSTO outpatient mental health plan highly.

IV. If they like the POSTO design, may it be feasible to offer such a design in the marketplace at a reasonably cost-neutral premium?

The focus group’s answer was qualified but was basically a strong yes. Chapter 5 explores this question and concludes that it is feasible. A very senior health insurance underwriter conducted a pro-bono independent study of the same subject and concurred with the dissertation’s feasibility conclusion. Further study by actuarial, marketing, new products, and public policy personnel will be necessary for further clarity.

V. If all of the answers are yes, then are there principles to bear especially in mind, if such a system were to be set up?

A further hypothesis was that a POSTO managed care outpatient mental health would also provide a useful stimulus for the focus group itself to begin its own idealized system design imaging process. The third hour of the three-hour focus group meeting asked the focus group to consider whether they had any recommendations they could agree on to help further development of public policy and plan design for covered outpatient mental health plan design.

As reported earlier in this chapter, the focus group brought together six priority recommendations of their own and voted for them almost unanimously. I concur heartily with each of their recommendations and recommend their further study.

Final thoughts

Strong evidence from multiple sources has substantiated the answer to each research question. The hypotheses have been supported, in a number of cases by multiple methods.

I do not see a particularly strong alternate explanation for the findings. The literature contained many sources describing these losses, from across the country, from among the different levels of licensure, and from across schools of therapy. The focus group simply buttresses strong existing literature evidence.

The literature study of covered outpatient mental health treatment found a distinct pattern of serious losses over recent years. The losses are experienced as very real and as very serious by the covered consumers and therapists involved, whose cases and profiles are being regularly reported in the literature. Given these serious losses, major stakeholders would benefit from creative dialogue, exploration, and design work together toward problem analysis and amelioration. Consumers and therapists raise an issue of fairness to the stakeholders, claiming that these losses aren’t "fair." This calls for talk among the parties.

POSTO is already a valued method for overall health plans as documented by the literature, but is not yet used for the outpatient mental health provisions of health plans. A substantial independent cost-neutrality feasibility study (Appendix 1) re-tested my own cost-neutrality feasibility study (Chapter 5) and concurs in my findings. The strong focus group support for POSTO managed care outpatient mental health plan design is consistent with the limited literature on the subject.

The cost-neutrality feasibility study with the Appendix 1 independent assessment both support feasibility and deserve more study and sophistication. More math, particularly actuarial, would be valuable to get more precision on certain number assumptions.

Although the focus group findings are consistent with findings in the literature, I won’t generalize about what happened. Still, the likeness of Likert results to reports in the literature suggest that replications would sustain or strengthen the positions the focus group took.

In the study of the resolution of conflict, one important behavior is to get in behind the present "positions" of the stakeholders and seek, at a deeper level, creative ways to take care of each party’s basic human needs, to build proposals which serve the other parties’ hierarchy of needs as well. The POSTO design and the six recommendations provide a starting place for useful discussion among the parties which can identify "wins" for each party.

This study’s expert focus group held an exemplary dialogue; but, in general, out in the world where this struggle over the health plan coverage of outpatient psychotherapy is taking place, there may be a conceptual problem in which stakeholder groups can be under the misapprehension that not only are they "right" in the way they analyze managed care outpatient mental health issues, but also that they may be the "only right" thinkers. Most unfortunately, such a misapprehension closes off interest in the other party’s experiences and perceptions, which may be very different from one’s own but distinctly valuable in perspective. Focus groups composed of various stakeholder parties may be of help to the stakeholders now in stimulating multi-stakeholder dialogue. Further research could help explore how to facilitate connections between/among the stakeholder groups and their organizations and associations. It would be valuable to replicate this focus group process among the "covered" outpatient therapy stakeholders. It could stimulate study of some of the technical and mathematical issues in the outpatient therapy POSTO design and potential recommendations by public policy groups and health plans. Those with need to study these results include such organizations as health plans, employee unions, employers and employer coalitions, consumer organizations, city, county, state and Federal governments, their legislative and regulatory bodies, and multiple-stakeholder coalitions and study groups.

In addition and perhaps most critically, for the long run, further research could prove more precisely the size and significance of the medical cost-offset effect. Such results could substantiate the logic for a more robust and "user-friendly" outpatient therapy and psycho-education program on the part of the health plan.

Bohart, O’Hara, and Leitner (1998) conclude that the relationship between therapist and client is, in their judgment, the most important aspect of therapy and thus the best predictor of successful outpatient therapy outcome. Because of this, addressing the problems explored here can be seen as particularly important.

Further multi-stakeholder discussions of the need to ameliorate the losses can bring other new approaches forward, as well. Although the research presented in this dissertation may be useful, it is only one approach, and, in this crisis of loss, all approaches deserve open-minded scrutiny.

If stakeholder parties would only study and plan together, they may be able to reach conclusions on design and practice which could lead to amelioration of the important losses. These could be incorporated into the plan designs directly or through statute, if necessary. I think this could lead to collaborative agreements which develop into effective humane cost-containment, distinctly good for the deep interests behind each party’s "bottom lines."

Finally, perhaps we see the profound losses to covered outpatient psychotherapy and the consequent suffering as an unintended side consequence of the managed care mass movement of the last dozen years. Whether or not the losses were unintended, the parties involved must come to see that these losses can be and deserve to be repaired.

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