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By Sean Smith
What do you do if, like CIGNA Behavioral Health (CBH), you realize
that the providers in your network appear to be doing just fine
with minimal utilization-care management oversight? In CBH's case,
the solution seemed clear: Make it easier for providers to serve
their patients.
That, in a nutshell, was the rationale for Minnesota-based CBH
to introduce a new policy last month that gives its 14 million consumers
open access to their outpatient mental health benefits.
Under the new policy, which was effective July 1, psychologists
and other providers can offer routine outpatient care to CBH patients
without prior authorization. In addition, providers no longer need
to prepare outpatient treatment reviews before further authorization
of their patients' benefits.
The six New England states are among those where CBH provides services.
CBH officials say the new policy will help focus its benefit management
services to assist providers in dealing with patients who have more
complex and intensive mental health and substance abuse problems.
"We're not abdicating care management, we're just doing it differently,"
says CBH Vice President of Clinical Operations Jodi Aronson Prohofsky,
Ph.D. "The providers in CBH have been managing themselves very effectively.
So what we're saying is, essentially, let them do their work."
A subsidiary of CIGNA, CBH provides behavioral care benefit management,
employee assistance and work-life programs through health plans
offered by employers, HMOs, Taft-Hartley trusts and disability insurers.
CBH operates five care management centers around the United States,
supporting a national network of more than 47,000 independent psychiatrists,
psychologists and clinical social workers and some 4,000 facilities
and clinics.
Prohofsky estimates that the percentage of CBH's doctoral-level
providers is about 30 percent nationally and possibly higher in
New England. When CBH looked at its utilization-care management
data a few years ago, says Prohofsky, the company was struck by
one finding: CBH was authorizing, on average, three more sessions
per case than providers were using. "This was, clearly, a situation
where our management process was not adding value," she says.
CBH decided to rebuild their claim systems to automatically highlight
complex outpatient or inpatient treatment cases such as eating disorders
or emotional problems of children or adolescents. But less intensive
outpatient cases will now be handled by providers without the initial
authorization of CBH managers. "We'll step in to help patients using
outpatient benefits if their treatment becomes more intensive, such
as if the number of therapy sessions is greater than two per week,"
Prohofsky says.
She notes the treatment of eating disorders, in particular, serves
as a useful illustration of how the new policy can better serve
both patients and providers. "These can be especially difficult
cases," she explains, "especially if the provider does not have
experience or expertise in diagnosing or treating eating disorders.
There's often a `honeymoon' phase where the patient appears to be
doing well, but then slips - and may wind up in a residential treatment
program."
"But if the claim is filed early on - and on average providers
do this every 2.6 sessions - we can offer the therapist some additional
resources like referrals or consults to assist in the treatment.
And, most importantly, we can establish a line of communication
with provider and patient," Prohofsky says.
CBH officials add that consumers, as always, have the option of
calling the company about referrals or assistance with their benefits.
"Our providers, we believe, do an outstanding job of marketing CBH,"
says Prohofsky. "So we have removed the barrier for the consumer
to go to a contracted provider for some outpatient treatments.
Massachusetts Psychological Association Executive Director Elena
Eisman, Ed.D., hails the CBH policy. "It is an interesting, forward-thinking
approach," she says. "To have delivery of services based around
benefit and professional discretion is the ideal model for mental
health care."
Eisman says the results of CBH's self-study, which helped prompt
its decision to enact the open-access policy, provide further evidence
that, contrary to the impression that providers overestimate their
patients' therapeutic needs, health care companies tend to authorize
more treatment sessions than are utilized.
As worthy as the policy is, Eisman says she's not convinced CBH
needs to step in to such a degree on more serious cases. "Our experience
is that providers know when they need a referral," she says. "They
are often more successful in finding one on their own than going
through an 800 number."
Prohofsky says the policy change has elicited positive responses
from consumers and providers and its effectiveness could have far-reaching
implications for mental health care. "It will not be long before
customers demand this of other managed care companies," she says.
Daniel Abrahamson, Ph.D., director of professional affairs for
the Connecticut Psychological Association says he is unfamiliar
with the new CBH policy. But he expresses cautious optimism that
open-access policy might help bring change to CBH's performance
in Connecticut for the better.
"For those of us in the state who have been tracking CIGNA during
the past 15 years, they've been the worst of the worst," Abrahamson
says. "Providers and consumers have complained that their policies
are redundant, restrictive and abusive and put all kinds of obstacles
in the way."
Abrahamson says that he finds it "interesting" that the policy
was enacted at a time when CIGNA is continuing to experience financial
problems. CIGNA recently announced that it expects 2003 earnings
to be about $175 million lower than it had originally anticipated,
of which $135 million reflects higher medical costs and the remaining
$40 million a smaller membership base. The company also replaced
the head of its health care operations this summer.
"I'm hopeful that (the open-access policy) is a harbinger of things
to come, but the devil is in the details. Based on what's been observed
in the industry, managing outpatient health benefits is generally
not cost-effective," he says.
Eisman also offers a cautious view. "If this kind of policy saves
money or doesn't cost more then it might become more widespread.
Unfortunately, I think that's what will ultimately be the determining
factor. Still, this is a positive development so we need to follow
its progress and see the data is evaluated and used appropriately,"
she says.
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