Authorization Standards for Inpatient Psychiatric Hospital Utilization Review
Specialty managed care organizations that focus on administering behavioral wellness and substance abuse benefits accept emerged as a major forcefulness in the mental health care market. These managed behavioral wellness organizations are now responsible for providing mental health benefits to the majority of privately insured Americans (1), and they have been shown to dramatically reduce costs compared with indemnity insurance and health maintenance organizations (HMOs) (2,3). Virtually managed behavioral wellness organizations are large, for-turn a profit organizations that contract with public and individual employers and operate beyond broad geographic areas. The industry is dominated by a handful of large managed behavioral health organizations, making it vitally important for u.s.a. to empathize exactly how these organizations operate.
Utilization management is i aspect of managed behavioral health organizations that has sparked considerable controversy. Utilization direction techniques take gained widespread credence by wellness plans, with approximately 90 per centum of individuals in private wellness insurance plans being covered by some form of utilization direction (four,5,half-dozen). The Institute of Medicine defines utilization direction as "a set of techniques used by or on behalf of purchasers of wellness care benefits to manage health intendance costs by influencing patient care decision-making through example-by-case assessments of the appropriateness of care prior to its provision" (7).
The nearly mutual utilization management techniques are precertification, concurrent review, and instance management (8,9,10,11). Precertification involves the blessing of services earlier commitment. Concurrent review focuses on authorization of additional services and length of stay. Case management incorporates both precertification and concurrent review in more than intense, ongoing review of care and tends to focus on high users of care.
While critics of utilization management practices are quick to bespeak out its flaws (12,13,14), most reports to date have been anecdotal, with little systematic testify to support their claims. Given the limited availability of information on utilization management patterns in mental health care, data on the bodily practices of managed behavioral wellness organizations are needed.
This newspaper presents a case written report of the utilization management program of a big managed behavioral health organization. We depict the utilization management process of 51 plans managed by United Behavioral Health (formerly U.S. Behavioral Health). We also report on the frequency and types of reviews performed and discuss the extent to which this utilization management program appears to ration use through the denial of services.
Methods
In September 1998 the first two authors visited the San Francisco function of United Behavioral Health to proceeds an understanding of their utilization management plan. The authors met with utilization management staff and observed a few instances of the review process in action equally care managers conducted bodily reviews on the telephone.
To understand the usual utilization management procedure at United Behavioral Health, we sampled information from 51 employer-sponsored plans. Nosotros included only those plans for which the enrolled population could be defined and for which the utilization direction program included standard reviews. A number of plans that had specific programs with additional or alternative reviews were excluded from this study.
The plans we studied had benefit designs roofing a total range of behavioral health and substance abuse services, with annual and lifetime limits, copayments, and deductibles varying beyond the plans. Twoscore-iv of the plans were point-of-service plans assuasive members to choose betwixt managed network and unmanaged services with differential coinsurance. Vii plans were sectional provider organizations roofing merely authorized services through network providers.
For our analyses nosotros looked at utilization review information from 1997. Claims data were used to determine the total number of members who used services in each plan. More data on the claims database and benefit design at United Behavioral Health tin be plant in a report by Sturm and McCulloch (15). The utilization review information were used to make up one's mind the frequencies of diverse types of reviews and the deportment associated with each review. Deportment were divided into "potency deportment" and "other actions." Nosotros defined say-so deportment equally decisions that led to authorization or denial of services. "Other deportment" represented a mix of pending decisions and information-gathering efforts. We were most interested in the authorization and denial patterns, and we focused our analysis on dominance actions rather than other deportment.
The review procedure
United Behavioral Wellness is the third largest managed behavioral wellness carve-out organisation in the land. Currently information technology manages mental health and chemical dependency benefits for about fifteen meg people nationwide. Its providers include psychiatrists, psychologists, social workers, and primary'southward-level therapists. United Behavioral Health does non capitate or directly employ any providers, and all providers are paid fee-for-service on the basis of one national fee schedule.
Figure 1 provides a schematic of the utilization management process at United Behavioral Wellness. Patients call a price-complimentary telephone number to request specialty mental health care or substance abuse services. Intake workers who are at least master's-level mental wellness clinicians reply telephone calls from patients and, under routine circumstances, authorize initial outpatient visits (commonly ten) without requiring a precertification review. For high-gamble patients whose care may exist more complicated, the intake worker makes an extended phone assessment. Depending on the results, the intake worker may qualify initial outpatient services or transfer the patient to a intendance managing director for an evaluation for more than intensive services.
Care managers brand the majority of the utilization review decisions. This group is a mix of master'southward-level clinicians and psychologists, with an average of viii years of clinical experience. Occasionally a care director receives a request for services straight from a patient, just the majority of requests come from mental health providers who either ship in written requests forms or participate in brief phone interviews.
The intendance managers meet in teams daily to go over cases. A supervisor and a medical director are assigned to each squad. Supervisors sign off on any deprival of services and assist the intendance managers with difficult clinical decisions. Medical directors are involved in any denial decisions related to more than intensive treatments such as access to inpatient services or the concurrent review of astute care. The medical directors are too involved in the appeal process for denials. The utilization management program does not employ explicit guidelines or algorithms for conclusion making. Instead, it relies on the initial training of utilization management staff and the daily team meetings to provide consistency in the utilization direction decisions.
The utilization management programme typically carries out 11 types of review, as described in Tabular array 1. Vii reviews crave decisions about whether to qualify or deny services: requests for psychiatric or chemical dependency admission, level-of-intendance change, facility review, medication evaluation request, assessment and care recommendation, and outpatient review. Two boosted reviews—the facility discharge review and the postdischarge follow-upwards review—may occasionally be associated with authorization decisions, but their primary purpose is to collect information and facilitate the transition from inpatient to outpatient intendance. 2 other reviews—the extended phone assessment and the closing summary—only gather information and do non require say-so decisions.
Results
Of the 230,532 eligible members continuously enrolled in 1997 in the 51 plans, 4.1 per centum (Due north=9,401) used mental health or substance abuse services, and 3 percent (N=6,995) did so through United Behavioral Health'southward network providers. Of those who used network providers, 57.4 percentage (N=four,016) underwent at least ane review of whatever blazon. The hateful±SD number of reviews for this grouping was 2.4±2.66; 49.3 percent (N=1,979) had only one review, and 23.1 percent (Due north=928) had two reviews. Patients with five or more than reviews made up 11.4 percent (Due north=458) of patients who underwent reviews and deemed for 37.7 percent (N=iii,630) of the total number of reviews, which was ix,639. One patient received 59 reviews during 1997.
Table 1 lists and describes the different types of review in order of frequency. The most common type was outpatient review (concurrent review for additional outpatient therapy visits), representing 46 per centum of the total. The second most common was facility review (concurrent review for boosted facility days), representing 12.9 percent. In contrast, precertifications such as psychiatric inpatient admission requests and chemical dependency admission requests fabricated upwardly simply modest percentages, 4.6 percent and two.9 percent, respectively.
The number of actions (Northward=x,270) exceeded the number of reviews (N=9,639) considering a single review could take multiple actions. For example, one outpatient review could comprehend a awaiting determination and and then certification, resulting in two deportment for one review. When actions were classified into authorization actions and other actions, we found that authorizations made up 77.6 percent (North=vii,973) of the total, and other actions fabricated up 22.4 percent (Northward=2,297).
Every bit shown in Table ii, the vast bulk of authorizations—91.viii percent—were canonical at the level requested by the provider. One less mutual type of dominance action was certification of final visits, at 6 percent. Co-ordinate to United Behavioral Health, certification of terminal visits represents an agreement between the clinician and the care manager that the patient will not require services beyond the corporeality authorized for the final visits. It is unclear to what extent the potency of final visits might have limited outpatient visits. Rare authorization deportment included certifications below the level requested (ane.three per centum), denials of services (.8 percent), certifications above the level requested (nine actions), and exhaustion of benefits (six actions).
Table 2 besides shows the distribution of authorization deportment by review type. In all review types, very few services were denied. Although the proportion of denials was slightly greater for discharge follow-upwards reviews (2.7 percent) than for other types of reviews, information technology is based on merely two cases and is probably not meaningful.
Very few services were approved at a level lower than requested by the provider. Notwithstanding, a slightly higher percentage of reviews for chemic dependency admissions (three.9 percent) and level-of-intendance changes (iii percent) were authorized at levels lower than requested, suggesting a tendency to divert patients away from more inpatient chemical dependency handling and higher levels of inpatient care, but here too the numbers were quite modest. Outpatient reviews had considerably more certifications of concluding visits (11.1 percentage) than the other types of review, and a lower percentage of reviews certified at the level requested (86.seven percent). Closing summaries and extended phone assessments did non take last actions associated with them and are not included in Table two.
Word
To our knowledge, this is the first paper to provide a detailed description of the operations of a utilization direction plan of a big managed behavioral health organization. We were struck by the telescopic of the program and the considerable free energy and resource it required. We found that reviews were not express to authorization decisions simply also included data gathering (extended phone assessments and endmost summaries) and efforts to promote continuity of care (facility discharge reviews and discharge follow-up reviews).
Although an active approach may be lauded for its business organization with patient intendance, it can also be experienced as intrusive and time consuming by providers (12,13,14). We institute that utilization management was frequently employed, with more half of the patients who used United Behavioral Wellness network providers undergoing some type of review. In a survey conducted by the American Medical Clan in 1990, psychiatrists reported spending more time dealing with external reviewers than did other physicians (16). The high frequency of reviews thus raises questions about the fourth dimension costs the review process may have for clinicians.
How practise utilization management programs exert their influence? A common perception has been that managed behavioral health organizations are overly restrictive and limit use of services through inappropriately high denial rates (12,14). Wickizer and associates (17,18,nineteen) reported that a utilization management program for a managed fee-for-service health care plan had low rates of preadmission denials merely appeared to limit hospital care by managing the length of stay through concurrent review. In this study, our findings were somewhat dissimilar. Although United Behavioral Wellness frequently employed concurrent reviews in both inpatient and outpatient settings, nosotros found exceedingly low denial rates regardless of review type or handling setting. Even if we include authorizations that were approved at lower levels than requested, nosotros found very little overt rationing of services, with the vast bulk of services canonical at the requested level.
It should be noted that depression denial rates do not necessarily mean that utilization management programs are ineffective at altering utilization. Previous studies have found that managed behavioral health organizations substantially reduce costs and utilization rates (2,3,xx,21). In addition to explicit rationing, clinicians' beliefs may be shaped by less overt just nonetheless powerful pressures. It has been suggested that managed care may have a more full general influence on the practice patterns of clinicians (22,23). The low denial rates we observed may be the production of clinicians' learning. Over fourth dimension, providers may have altered their clinical determination-making patterns to conform with the intensity of services that managed behavioral health organizations volition reimburse. Unfortunately, we do non accept access to United Behavioral Health data from before the implementation of the utilization management program to accost this question.
Utilization management programs may also exert their influence on clinicians through the picket effect or the hassle factor associated with obtaining authorizations. The sentinel issue is a decrease in services given by providers as a consequence of having a utilization reviewer keep tabs on them (24), and the hassle factor includes excessive paperwork and fourth dimension-consuming telephone calls related to the utilization management process (25). Both of these factors can make providers less inclined to request additional services and would not exist reflected in denial rates.
It is likewise possible that providers have learned how to get their requests authorized. Rather than changing their clinical behavior, they may simply be condign more savvy about navigating the utilization direction process and getting requests approved. Given the decreased utilization associated with managed behavioral health organizations (20), yet, increased ability to navigate the process seems unlikely to explain the depression denial rates we observed.
Managed behavioral health organizations may too control utilization through the choice of providers for their network. Some managed behavioral health organizations may use provider profiling to remove clinicians who request also many services from their panels (26). High deprival rates may not be necessary if the managed behavioral health organization builds its network with clinicians who provide levels of intendance consequent with expected utilization rates.
Given the public's strong negative sentiment toward managed care, there may exist increasing pressure level on managed behavioral wellness organizations to minimize their overt denial of care. In this highly competitive mental health care marketplace, depression deprival rates in addition to price savings may be bonny to purchasers of mental wellness benefits. Our written report reports only on employer-based plans and does not examine managed behavioral health organizations in the public sector. As state and local governments increasingly contract with managed behavioral wellness organizations, it will be of import to run into how well these utilization management techniques interpret and whether the same low denial rates are possible in the public sector.
Several important issues are non examined in this study. Our analysis does not accost the appropriateness of the decisions made by the utilization reviewers. We still practice not know what the effect of utilization management is on toll or on quality of care. Further inquiry is needed on the price-effectiveness of the utilization management procedure and on its touch on on quality of mental health intendance.
Because our analysis was limited to administrative data, we tin can report just on denials as narrowly defined past United Behavioral Health. There may be deprival equivalents that limit care but are not captured in utilization management records. For example, nosotros cannot measure the content of the interactions between provider and care manager and practice not know how much negotiation and compromise get into the authorization process. Intendance managers may tell providers what they will qualify rather than ask providers what services are needed, and this process may be recorded every bit an approval at the level requested. For a more complete picture of the utilization management process, information technology would exist important to examine the perceptions of United Behavioral Health providers.
Our site visit was used to inform our quantitative analysis. We did non comport a formal qualitative study of the utilization management programme, which might have provided useful additional information. It is possible that the 51 plans we analyzed are not representative of the utilization management program as a whole. However, according to United Behavioral Health officials, the utilization management program should not differ greatly amongst plans, and in a preliminary look at the excluded plans, we found similar denial rates.
The generalizability of our results is limited, since we report on a unmarried utilization management program. It is unclear whether the utilization direction process and authorization rates we describe are unique to this item organization or whether these features are characteristic of the industry. That United Behavioral Health has given united states of america access to its data could advise that its utilization management process is different from the procedure used by other companies. Utilization direction programs vary widely in personnel and the clinical criteria used to authorize care (8,11). An interesting question is whether denial rates would be different in a system that uses explicit guidelines for review.
Conclusions
Although a number of writers accept deplored the high deprival-of-care rates in utilization direction programs, this study plant very low denial rates at United Behavioral Wellness. While it remains unclear how utilization management programs exert their influence, access to intendance at this particular managed behavioral health organization does not seem to be limited through overt denial of services. Further studies are needed to determine the precise mechanisms utilization management uses to command utilization. Particularly important would be to investigate whether utilization management shapes provider behavior directly or through a hassle factor. For this, some means of measuring the hassle factor is needed. A survey of United Behavioral Wellness providers to assist address this question is planned.
The large number of utilization reviews raises boosted questions almost the cost of the review process in clinicians' time every bit well as in opportunity costs. How much time and coin does the utilization direction process consume at managed behavioral wellness organizations? Tin can any of the process be eliminated without affecting quality of intendance? Future research should examine the value added for the resources spent on the utilization management procedure.
Acknowledgments
Financial support was provided past the National Institute of Mental Health through grants MH-54623 and MH-00990. The authors thank United Behavioral Health for admission to its data and its organization, and Joyce McCulloch, M.South., Brian Cuffel, Ph.D., and William Goldman, Chiliad.D., for their assistance. They as well give thanks Roland Sturm, Ph.D., Ken Wells, M.D., and Arlene Fink, Ph.D., for comments on an earlier version of this article, and Xiaofeng Liu, K.S., for statistical back up.
Dr. Koike is assistant professor in the department of psychiatry at the University of California, Davis, and is affiliated with the kinesthesia scholars program of the Academy of California, Los Angeles (UCLA). Dr. Klap is a researcher at the Research Center on Managed Care for Psychiatric Disorders and Dr. Unützer is assistant professor in residence in the department of psychiatry and behavioral sciences at UCLA. Dr. Unützer and Dr. Klap are too affiliated with the UCLA Neuropsychiatric Constitute and Hospital. Accost correspondence to Dr. Koike at 10920 Wilshire Boulevard, Suite 300, Los Angeles, California 90024 (e-mail, [e-mail protected]).
Effigy i. The utilization management process at United Behavioral Healthane
1 Ovals betoken personnel; rectangles bespeak reviews
Table one. Type and frequency of reviews conducted by United Behavioral Health
Table ane. Blazon and frequency of reviews conducted past United Behavioral Health
Enlarge table
Tabular array ii. Frequency of authorizations deportment by review typeane
Table 2. Frequency of authorizations actions by review type1
Overstate table
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Source: https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.51.5.621
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