Entering the new frontier of managed mental health care: Gold mines and land mines

COGNITIVEAND BEHAVIORALPRACTICEI, 5-23, 1994

Entering the New Frontier of Managed Mental Health Care: Gold Mines and Land Mines

Kirk Strosahl

Group Health Cooperative Of Puget Sound Seattle, Washington

This article examines issues that behavior therapists must address as they adapt to the new and complex trends of managed mental health care. The origins of the managed health care movement are reviewed. Major shifts in clinical practice will occur in four primary areas: viewing both the client and payer as "customers;' accepting accountability for clinical outcomes, providing efficient, empirically based care, and accepting the technical and ethical challenges of being both cost conscious and quality focused. Behaviorally trained clinicians and researchers will have many potential advantages working in the era of managed care. To capitalize on their background strengths, behavior therapists must learn to work with and not against managed care systems, learn the language necessary to have constructive, change-oriented dialogues with managed care executives, and learn to conduct "field based" research to answer important questions about the clinical efficacy and cost efficiency of behavioral interventions. Finally, the behaviorally trained clinician should try to find the right "fit" between practice style preferences and choice of managed care setting.

It has been nearly two decades since the H M O Act of 1974 legitimized m a n a g e d health care as a service delivery strategy. T h e eventual consequence of escalating m e n t a l health care costs has been the m i g r a t i o n of m a n a g e d health care strategies into the mental health industry (Bennett, 1988; C u m m i n g s , 1986). Although m a n y mental health practitioners have adapted to a n d capitalized upon the challenges and opportunities presented by m a n a g e d care, the "mainstream" 5

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Copyright 1994 by Associationfor Advancementof Behavior Therapy All rights of reproduction in any form reserved.

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response in the mental health industry has been to resist. Stories of abuses by managed care companies have created a variety of negative stereotypes (Buie, 1987; Lange, Chandler-Guy, Forti, Foster-Moore, & Rohman, 1988; Levenson, 1987). The response of the national trade associations (American Psychological Association, American Psychiatric Association) has been to portray managed care as a threat to the basic livelihood of practitioners. For example, both associations have instituted special levies to support a counter-campaign against the incorporation of managed care as a cornerstone of national health care reform. There is now an uneasy recognition among most behaviorally trained clinicians and researchers that managed mental health care is here to stay. As a business philosophy, it has proven to produce an effective set of strategies for reducing the health and mental health care costs incurred by government and business (Shoor, 1993). Despite the badly misguided resistance still evident in the trade associations, a tremendous opportunity remains for those who are willing to make the philosophical and clinical shifts required to participate in this new journey (Cummings, 1988). The purpose of this article is to examine managed mental health care from an optimistic perspective: How to embrace, work with, and shape the processes supporting managed mental health care. Like any new set of business practices, managed care has many problems. Most practitioners have at least some negative experiences with managed care systems. In this early stage of development, the environment is ripe for "bottom feeders" who enter the managed care business with the primary goal of getting rich quick and retiring. In some cases, companies are so large and poorly coordinated that decision making is left to the least qualified. Still other companies use clinically inappropriate standards of care to justify reimbursement practices. Many practitioners complain about the overwhelming amount of paperwork required to receive compensation for services rendered. It is very legitimate to be concerned about the future of mental health care if one were to mistake today's managed care for the finished product. In reality, the entire field of managed care is undergoing a tremendous transition as well. At least one component of this transition is an increased emphasis on cost containment through the provision of quality services, as opposed to cutting services. As business and insurance increasingly grow aware of the long term costs associated with inadequate (although cheap) care, managed care companies that make money by denying services are headed for oblivion. Managed care systems in the future are going to be "on the hook" for cost containment, quality clinical outcomes, and satisfied customers. During this transitional era, clinicians and researchers must learn strategies to avoid the land mines posed by managed care systems while remaining focused on the gold mine of opportunities offered by the managed care movement. For the behaviorally trained clinician involved in managed care, each stage in the treatment planning, execution, and evaluation process brings up "mile-

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posts" or points where clinical decision making must include managed care concepts and address corresponding ethical questions. Some of these concepts will expand traditional notions of mental health care; others will seem philosophicaUy consistent; still others will make a great deal of sense and leave us wondering why they have not been included in our decision making all along. Hopefully, the directions supplied herein will guide both clinicians and researchers on what promises to be a long and interesting journey. H o w Did This All Come About?

Ironically, mental health providers are victims of their own success. Mental health care in the United States has evolved from a "cottage industry" to a major industry, consuming approximately ten cents of every health care dollar annually. This 50-year transition may be attributed to three principal socioeconomic trends. The first trend is a growing involvement in the business of health care by state and federal governments through such programs as Medicare, Medicaid, and C H A M P U S . In no small measure, government decisions regarding which services will be subsidized and the mechanisms for reimbursement have consistently established health care reimbursement policy in business and industry. A second trend is the growing importance of insurance and industry in the health care process. In other words, insurance has largely replaced "out of pocket" methods of payrnent, to the point that universal health care coverage is now espoused as a basic right of citizenship. The result is that business and industry are being hit hard by the effects of increased health care costs in employer subsidized benefit packages. For example, a recent Foster-Higgens survey of business benefits managers revealed that, over a 5-year period from 1987 to 1992, the average yearly premium per employee for combined mental health and substance abuse had increased from $163.00 per employee to $318.00, for a total increase of nearly 100% (Shoor, 1993). The third trend has been termed the "industrialization" of mental health (Bittker, 1985). This involves the inclusion of mental health insurance in basic health insurance packages and the break-up of the monopoly enjoyed by psychiatry with respect to third party insurance coverage. This process has been influenced by the aging of the "Baby Boom" generation, a population cohort that has demonstrated an unprecedented willingness to seek mental health services. The point of this historical sketch is to illustrate that (1) the psychotherapy client is not the only payer in the average case and (2) the employer-payer is running out of money at the same time that (3) clients are accessing mental health services at an all time high. Further, both business and government have been frustrated by the inability of the health care professions to self-regulate costs. Managed care strategies have proven to be one widely accepted method for

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b r i n g i n g the cost spiral u n d e r control. Business a n d health j o u r n a l s are full of positive stories about m a n a g e d care systems significantly reducing mental health care costs (Shoor, 1993). T h e two other m a i n cost control strategies that companies use will be less attractive in the long r u n to m e n t a l health practitioners: eliminating mental health benefits altogether or imposing significant co-insurance requirements. Both will have the impact of discouraging clients from using mental health services. Strangely enough, the best outcome for the m e n t a l health industry could be the i m p l e m e n t a t i o n of m a n a g e d care as the p r i m a r y methodology in health care reform.

B a l a n c i n g Beliefs A b o u t M a n a g e d Care I n order to form a constructive dialogue with m a n a g e d care systems, certain beliefs that may prevent a collaborative stance need to be balanced. These beliefs result in a sense of loss and victimization that can paralyze creative problem solving at the individual or organizational level. M a n a g e d Care Is Against God, Mother, and Apple Pie M a n a g e d care is not a conspiracy hatched by m o n e y h u n g r y business executives, with the goal of depriving clients of needed mental health care. There are, in fact, a bewildering variety of m a n a g e d care strategies. T h e y exist at both the private and governmental level. As is illustrated in Tables i, 2, & 3, m a n a g e d care strategies typically involve benefit design, practitioner/facility review and/or

TABLE 1 MANAGEDMENTALHEALTHCARE CHARACTERISTICS:BENEFITDESIGN Strategy

Function

1. Free session limits (up to ten sessions)

1. Allow initial access; discourage intense use by putting client at risk;

2. Co-payments (up to 50% of session cost)

1. At high levels, deflect all but essential service; 2. At low levels, recapture some of coverage premium; 3. Financial risk to client tends to limit usage;

3. Psychiatric exclusion

1. Eliminates "sicker" patients, reduces use;

4. Preexisting condition exclusion

1. Eliminate repeat services for same disorder;

5. Non-covered services

1. Limits types of services available, reduces plan cost;

6. Physician referral requirement

1. Places barrier to service, reduces utilization; 2. Increases likelihood treatment will occur in less expensive primary care setting.

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TABLE 2 MANAGED MENTAL HEALTH CHARACTERISTICS: pRACTITIONER AND FACILITY MONITORING Strategy

Function

1. Precertification

1. Allows front end control of treatment planning; 2. Controls unnecessary tests and treatment; 3. Matches level of care to level of need;

2. Mandatory review session limits

1. Identifies high risk situations early; 2. Mid-point review limits length of treatment; 3. Stops ineffective treatment;

3. Post-hoc utilization review

1. Places client/therapist at risk for unnecessary treatment costs by requiring treatment matching;

4. Practice profiling

1. Identifies therapists who are consistent outliers; 2. Triggers practice management strategies to bring costs down;

delivery system design. The key ingredients in cost effective benefit design are to limit covered services (i.e., limit number of psychotherapy sessions or days of covered in-patient care) and/or make the client share part of the cost of receiving services (co-payments or co-insurance). In contrast, practitioner and facility review strategies focus on limiting payments for services by specifying what type TABLE 3 MANAGED MENTAL HEALTH CHARACTERISTICS: DELIVERY SYSTEM DESIGN Strategy

Function

1. Health maintenance organization (HMO); usually prepaid benefit designs, makes extensive use of capitation model

1. Reduce cost through prevention, low rate of hospitalization, briefer out-patient care, medical cost-offset;

2. Preferred provider organization (PPO); usually based in co-payment benefit design

1. Payer-provider agreement reduces session costs, insures referral volume; 2. Helps utilization review;

3. Individual practice association (IPA); uses prepaid health care or co-payment benefit designs

1. Group contract shifts cost control incentive to provider group; 2. Helps utilization review

4. Employee Assistance Program; usually limited to 1 to 3 free visits per referral episode, assessment and referral only

1. Deflects use away from expensive mental health services; 2. Streamlines referral process; 3. Acts as proxy for company in focusing treatment, reducing disability time; 4. Emphasizes prevention and early identification to reduce intensity of secondary treatment;

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and what amount of services are "medically necessary" to treat a certain condition. Services provided in excess of these limits are charged back to the provider and, ultimately, the client. In general, delivery system design strategies focus on using a population based approach to care, in which a fixed rate or pre-paid capitation financing method is employed to limit the health care purchaser's financial liability. The underlying goal of these strategies is to put the provider and/or the patient more "at risk" financially and create a service delivery climate in which only necessary treatment is provided. A widely held belief in business as well as in government is that much unnecessary treatment is being delivered by mental health providers. The most attractive option for the payers is to create more restrictive compensation practices to curtail unnecessary treatment.

Quality Is J o b Two A second belief is that managed care is a cost control movement with no real investment in quality clinical outcomes. The truth is that business and government are extremely concerned about maintaining a healthy work force. For example, many business executives have first hand experience with the hidden costs of depression, e.g., absenteeism, lost productivity, and employee termination (cf., Shoor, 1993; Wells et al., 1989). The amazing growth of the Employee Assistance Program (EAP) model in American business is convincing evidence of the premium placed on maintaining mentally and physically healthy employees. The "Quality Revolution" sweeping business and health care will influence profoundly the evolution of managed care through the Total Quality triad: (1) Good clinical outcomes, (2) customer satisfaction with the process of care, and (3) a minimum of resource use (el., Berwick, 1989). The argument over whether quality is a priority is a "straw man;" the real issue is the need to demonstrate quality at an acceptable price. For example, take a client who is being treated for major depression, who has experienced deficits in both job and family functioning. A quality clinical outcome would involve not only a reduction in the patient's depressive symptoms, but also improvements in work performance (i.e., less absenteeism, increased productivity) and family functioning (more time spent in family activities, less time spent isolated watching T.V.). Both of these outcome dimensions would require some objective type of measurement both pre- and posttreatment. Further, the patient and the health care purchaser should report high satisfaction with the process of care, again measured through some type of structured interview or self report based consumer survey. Did the patient have immediate access to needed services? Did the patient have easy access to follow-up appointments? Was care coordinated with any concurrent medical or psychiatric care?

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Did the provider coordinate a return to work plan with the client employer? Finally, an acceptable price is determined by how many psychotherapy sessions and adjunctive services were needed to achieve this outcome. Regardless of the clinical outcome or customer satisfaction achieved in this episode of care, if it required 36 psychotherapy sessions (@$100.00/session) and 10 psychiatric medication visits (@$150.00/session) to achieve these results with an uncomplicated depression, the price is probably not acceptable. Economic Incentives Are Perverse One common belief is that the current practice of mental health care is free of perverse economic incentives, whereas managed mental health care is all about money, or saving money, to be exact. Is it reasonable to contend that anyone can deliver mental health services free from economic influences? Any private practitioner can attest to the intense economic pressures of operating a private practice, especially when referrals are down and rent and payroll are due. In managed mental health care, the incentives change from making money by delivering more services to making money by being efficient and producing quality outcomes. A balanced way to approach this issue is to understand that all clinical practice occurs in an economic context and all practitioners are influenced by the economic context in which they work. Loss of Autonomy and Altruism Many mental health providers feel that it violates the "spirit" of the mental health profession to acknowledge that it is a business, like any other business. Having one's care reviewed and managed can be threatening and disempowering at the same time. The fact is there wouldn't be a mental health "industry" but for the grace of the business, insurance, and government. Ultimately, a more balanced approach may be to acknowledge the right of the "payer" to review the product, while at the same time feeling empowered to require and, if necessary, fight for a sound review process.

Advantages of the Behaviorally Trained Clinician The managed mental health care movement is going to wreak havoc with clinicians who develop vague and global treatment plans, use a "one size fits all" approach to treatment, encourage discovery of new presenting problems as therapy wears on, and fail to track clinical outcome in some type of objective way. Fortunately, this author would like to think that this description is the antithesis of the "behaviorally trained clinician: The behaviorally trained clinician and researcher have skills which nicely mesh with emerging goals of managed care. For example, many systems employ

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assessment protocols which (1) provide a quantifiable measure of the patient's symptoms, (2) result in a D S M - I I I R diagnosis and (3) suggest both an intensity and type of treatment. There is a growing interest in assessing both clinical outcomes and customer satisfaction in managed care systems. For example, Harvard Community Health Plan has implemented an interview based patient assessment tool that objectively quantifies a patient's clinical status at entry into treatment, specifies a given level and type of treatment, and monitors the patient's response to treatment (Fitzpatrick, 1992). The tool assigns numerical ratings to a number of important dimensions that may potentially respond to treatment such as severity of psychiatric symptoms, general adaptational functioning, dangerousness to self or others, and level of substance abuse. Group Health Cooperative O f Puget Sound annually conducts a large scale phone interview survey to assess customer satisfaction with the process of health and mental health services, focusing on such important customer loyalty factors as ease of access to services, attitude of provider and support staff, coordination of medical and non-medical care, and the patient's perception of technical quality of care. Integra Healthcare Systems has recently introduced the COMPASS outcome assessment system (Brill, Grissom, Howard, Malcolm, & McLellan, 1993). Based in the dose-effect and stages of psychotherapy change research by Howard and associates, COMPASS is a multi-modal battery measuring the client's treatment motivation, severity and type of presenting problem, subjective well-being, current life functioning, and seven common D S M - I I I - R conditions. Clinicians also provide independent ratings of global functioning and ratings for six different areas of current life functioning. The patient's well being, symptom based and functionality scores are combined to form a Global Mental Health Index. The clinician ratings are combined to form a Clinician Assessment Index. The internal consistency coefficients for these two indices are .86 and .84, respectively. Patients and therapists complete these ratings every 4 weeks and treatment progress is tracked using"dose-effect" prediction curves and normative cut-off criterion that specify when therapy is unlikely to produce further cost justified benefits. In conclusion, managed care systems are not only increasing the emphasis on quantifying clinical and functional outcomes, customer satisfaction and cost to produce outcome, but also are using cutting edge technology to do so. Because of its long tradition of focused, efficacy based treatments, behavior therapy enjoys a positive image in the managed mental health care industry (Armenti, 1991, 1993). This positive image is demonstrated graphically in a study of 293 therapists in H M O ' s (Austad, Sherman, & Holstein, 1993). Most of the therapists indicated their initial training had been psychodynamic in orientation (46%); few were behaviorally trained (13%). However, a majority of the therapists indicated their current approach to therapy was either eclectic (35%) or behavioral (24%)! What might explain this highly favorable status? First, behavioral interven-

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tions have an established efficacy with many types of mental health problems. Second, these interventions tend to be time effective. Third, the availability of reliable and valid outcome measures such as the Social Avoidance and Distress Scale or the Beck Anxiety Inventory lets therapists "see" rather than guess that the treatment is working. In essence, the behavioral practice style strongly supports the goals of both managed care clinicians and administrators. This author believes that mental health and health care systems largely will become much more integrated in the decade of health care reform. There is a growing recognition, sparked by the Epidemiological Catchment Area Study, that the primary care medical system is the de facto mental health system of the United States (Narrow, Regier, Rae, Manderscheid, & Locke, 1993). Further research demonstrates both the health cost impact of untreated or inappropriately treated mental health problems (Wells et al., 1989) and a huge potential for offsetting medical costs by providing mental health services in general health care settings (cf., Cummings & Follette, 1968; Mumford, Schlesinger, Glass, Patrick, & Cuerdon, 1984). Interestingly, the "pace" of general health care strongly favors the skills of the behaviorally trained clinician. In the context of the "15 minute hour" (i.e., the typical time block for a primary care medical visit), primary health care providers have become "ad hoc" behaviorists. Behavioral treatments enjoy a very positive image in the general health care system because they are easily adapted to the physician "advice giving" model of health care. Health-mental health integration will provide endless opportunities for behaviorally trained clinicians to act as therapists, consultants, and trainers in general health care. Although the new frontier is full of opportunities for the behaviorally trained clinician and researcher, the journey will involve addressing professional values, modifying clinical strategies, and resolving some ethical dilemmas.

Some Professional Mileposts Mile-Post One: Who Is The Customer? When you begin therapy with a client, you are serving multiple interests and you need to be clear who they are. First and foremost, your client wants your help in feeling better and also wants you to represent his/her best mental health interests in any interactions with other customers. Second, the payer has definite interests which you need to see as legitimate. For example, the business that carries health insurance for your client may have goals you haven't considered. For example, check out how often your patient is leaving work early or calling in sick for mental health reasons. If your client is on a leave of absence from work, you can be sure that the supervisor will want to talk with you about a return to work date and plan. There may be an Employee Assistance Program (EAP) specialist involved who is also a customer. That person's job is to refer the client to the right kind of treatment and implement a return-to-work plan

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as soon as possible. T h e utilization review ( U R ) company is also your customer; it serves as a proxy for the insurance carrier whose goal is to reduce waste while m a i n t a i n i n g or i m p r o v i n g quality. This will keep insurance p r e m i u m s down. T h e r e are ethical d i l e m m a s associated with having so m a n y customers. It is easy to over-simplify the situation by taking an "us versus them" approach. You tell your client that "the system" is to b l a m e for any restrictions in care that occur as a result of a U R decision. You begin to see the client as being "victimized" because you are being held accountable for the cost a n d quality of your services. Conversely, you begin m a k i n g t r e a t m e n t decisions based solely on economics or engage in half-hearted treatment, anticipating a loss of coverage for your client. T h e r e are no easy answers. T h e best a p p r o a c h is to see yourself as a "supplier" to a n u m b e r of different customers. Everyone is concerned a b o u t both quality a n d cost. Your n u m b e r one p r i o r i t y is to m a i n t a i n a field of integrity a r o u n d your clinical decision making, Your ability to make things work in this complex swirl is your chief strength. TABLE 4 GLOSSARY OF KEY MANAGED MENTAL HEALTH CARE CONCEPTS Term

Definition

Aggressive alternative care/ diversionary care

Treatment designed to avoid more expensive care by providing some but not all d e m e n t s of the more intensive, expensive care (i.e., acute care respite bed vs. inpatient hospitalization)

ALOS

Average length of stay; How m a n y days the average in-patient spends in the hospital;

Capitation

Prepaid health care financing method based on age and sex adjusted utilization;

C o n t i n u u m of Care

Treatment services cover the range of potential needs;

Covered lives

N u m b e r of workers and their dependents in a particular plan;

Customer satisfaction

The client's assessment of the process of care (i.e., access, timing of appointments, courtesy of office staff);

Customer, supplier and payer

The basic triad of third party insurance.

Evidence based care

Treatment is based on research; current outcome is being objectively assessed;

External vendor

A company contracted to supply a product or service to another company (i.e., UP, company contracted by an insurance company);

Medical cost offset

Reduced medical costs produced by providing mental health services to a particular client.

Medical necessity

Basic concept of utilization review. Means treatment was required on the basis of severity criteria. continued

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M i l e - P o s t Two: W h e n in R o m e , D o As T h e R o m a n s D o It is i m p o r t a n t t h a t you l e a r n the l a n g u a g e of m a n a g e d m e n t a l h e a l t h care. Table 4 p r e s e n t s a glossary o f c u r r e n t t e r m s a n d t h e i r i m p l i e d m e a n i n g . For e x a m p l e , w h e n you state you practice time-effective t r e a t m e n t , you are indic a t i n g you can b e t r u s t e d to be cost conscious. You m u s t tailor y o u r d i a l o g u e s to the a u d i e n c e . W h e n s p e a k i n g to a p o o r l y t r a i n e d U R specialist (soon to be a t h i n g of the past), don't cite esoteric clinical studies in a condescending, belittling tone. F i n d a way to "connect" to that person's level of awareness a b o u t m e n t a l h e a l t h issues. Try to get the p e r s o n to h e l p you by g o i n g t h r o u g h q u e s t i o n a b l e certification criteria. S y m p a t h i z e w i t h how t o u g h it m u s t be to have to say " n o ; often for c o n f u s i n g o r c o n t r a d i c t o r y reasons. O f f e r suggestions u s i n g "facts" a n d "results" o r i e n t e d l a n g u a g e ; don't e x a g g e r a t e based o n y o u r o w n biases. Self-restraint will facilitate y o u r n e g o t i a t i o n s w i t h the w o r l d of business, i n s u r a n c e , a n d m a n a g e d care entities. T h i s is an e d u c a t i o n process, and, u n d e r o p t i m a l conditions, is reciprocal.

TABLE 4 CONTINUED

Term

Definition

Meet or exceed customer expectations

Popular slogan in TQM. Means the product or service is designed according to the customer's definition of quality.

Practice guideline

Treatment decision making algorithm that specifies the order and intensity of treatments for a condition.

PMPM

Per Member Per Month. The amount it costs to supply health care to one member of a health plan for a month. A basic unit of productivity;

Quality costs less

Key principle of TQ.M; A quality service may cost more to produce but makes more profit because of fewer defects and customer loyalty;

Time effective treatment

Treatment is effective, uses minimum resources

TQM (total quality management)

Management philosophy emphasizing customer satisfaction and product quality through statistical control processes;

Treatment matching

Using the "preferred" treatment at a specific intensity level for a particular condition;

Utilization

How much a particular service is used by a covered population; also used to describe the amount of services consumed in episode of care;

Utilization review (UR)

Process conducted before during or after treatment that determines what services are medically necessary and wiil be compensated.

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Mile-Post Three: Understand and Capitalize On Your Strengths There are many aspects of the behavioral approach that implicitly address the managed care goals of cost containment and quality clinical outcomes. Develop your practice style around these basic areas: Problem focused treatment, precision diagnostic/target problem assessment, treatment matching, and a focus on outcome assessment. When interviewing for a position in any type of managed care context (PPO, H M O , IPA), make sure to highlight these philosophies of care. Continually referring to your approach as "evidenced based care" communicates that you know the treatment outcome literature and use it in your practice. One principal strength of the behavior therapist is applied knowledge of both disorder specific treatment techniques and a general approach to "garden variety" complaints that tends to result in time limited and cost effective treatment. To remain in the optimal position in the managed care environment, you must be proficient with both specialized and generalized behavioral treatments. The reason: It is very likely that clinical guidelines will become the rule rather than the exception. Not only will a specific range of sessions be allocated for treatment of specific disorders, but managed care systems are likely to specify an acceptable type(s) of treatment, based on clinical outcome research.

Mile-Post Four: Change The Context And the Contract How you construct the dialogue with your client about what services you can and can't provide will be instrumental to your long term success. Some therapists just can't get over the fact that mental health care is no longer focused on "curing" the patient's personality flaws. They view the goal of increasing the client's current functioning through briefer interventions as a "rip-off". This ultimately results in poor clinical outcomes, higher drop-out rates, and dissatisfied customers--any one of these can be a land mine. Remember, most managed care networks are currently oversupplied with providers and are terminating contracts with all but the most effective clinicians. An alternative approach is to question sacred assumptions about what the client needs from therapy. Consider, for example, utilization research which consistently shows that 80% of all psychotherapy clients attend less than six sessions and the average number of therapy sessions used by clients across all settings is between 4 and 6 (Cummings, 1991; Howard, Davidson, O'Mahoney, Orlinsky, & Brown, 1989; Phillips, 1985). Further research indicates that fully 90% of all patients can complete their treatment within the typical benefit structure of a managed care system, which usually will include up to 20 sessions of therapy yearly (Dorwart & Epstein, 1992). Indeed, studies examining what clients want from therapy consistently reveal two desired outcomes: Emotional support and practical advice (Cummings, 1991). The process of change in psychotherapy is also a case study in intriguing contradictions. Dose-effect meta-analyses demonstrate that fully half of the clinical benefit obtained in therapy occurs by the 8th session (Howard, Kopta, Krause, & Orlinsky, 1986). Interestingly, the vast majority of these studies have taken place in fee-for-service, community mental health, or training program settings,

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where the behavioral incentives favor prolonging the therapy process. In effect, very little is known about the dose-effect curve in managed care settings. The few scientifically acceptable investigations of managed mental health care and fee-for-service mental health treatment have found no differences in clinical outcomes in psychotherapy, but significant cost differences favoring managed care systems (Manning, Wells, & Benjamin, 1986; Rogers, Wells, Meredith, Sturm, & Burnam, 1993). The best study to date involved a 1-year randomized trial of patients assigned to either pre-paid mental health care in an H M O setting or indemnifiedmental health care using the fee for service sector (Manning, Wells, & Benjamin, 1986). The primary outcome measure was the Rand Mental Health Index, a measure of general psychological health that is sensitive to mental disorders as well as to changes in general psychological functioning. Results of the study revealed no differences in clinical outcomes as a function of treatment setting. However, outcomes were achieved using an average of 4.7 sessions in the H M O setting versus 16.9 sessions in the fee-for-service setting. The imputed cost savings associated with this difference was nearly 300% for patients treated in the H M O setting. Ironically, those clients who receive long term therapy constitute less than 15% of the client population but account for nearly 50% of the resource use (Howard et al., 1989; Taube, Burns, Goldman, & Ressler, 1988). This group of patients commonly is cited by opponents of managed care as likely to be deprived of needed services. The evidence regarding the efficacy of psychotherapy with these chronically distressed, high utilizing clients is far from convincing (Strosahl, 1991). There is growing concern that the main criteria for receiving long term psychotherapy is the failure to respond to all the therapy already administered, i.e., if the client doesn't benefit from treatment, more of it will be delivered (Chiles & Strosahl, in press). Although managed care allows the vast majority of clients to access needed services, the nature of the therapeutic contract must shift to include a joint recognition that resources are limited. Consequently, the goal of treatment is to get the client functioning and "back on the road" as quickly as possible. This means that every session must end with a mutual review of its impact. If the session had an impact, you and your client should collaborate on ways to enlarge the impact in between sessions. In general, the hardest clients to make this shift with are those who have been in prior therapy and believe their insurance entitles them to endless psychotherapy, whether it helps or not. The most effective rationale with this type of client is: "You've persisted in therapy and you are still hopeful that it will work. How about us taking a different approach this time and focusing on what you are ready and able to change?" Mile-Post Five: Be Like Mike (The Family Dentist) Research suggests that managed mental health care will impact practice style in two ways: (1) Fewer resources will be used in the average episode of care and

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(2) the percentage of the population accessing mental health services will increase (Wells, Manning, & Benjamin, 1986). This is why managed care principles are so intertwined with health care reform, with its emphasis on coverage for all. This pattern will have a profound impact on practice management and the nature of the therapeutic relationship. First, the long term therapy client has long been the backbone of private practice (Howard et al., 1989). As the length of long term service is reduced, the number of new clients needed to maintain a practice will increase, i.e., there is a referral base problem. An effective practice building and practice style management model may be intermittent care across the life cycle (cf., Cummings, 1991). Like the family dentist, you maintain a connection with the client over many years. There may be time limited episodes of care, sandwiched around yearly "check-ups". This means the pressure is off to perform miracle cures in any one episode of care. Experience suggests that each episode of care gets briefer (good for U R ) because you and the client have a past history of solving problems together (good for assuring quality). H M O managed care systems already rely on this model and it may become a dominant service delivery model in other managed care settings as well. Mile-Post Six: Differentiate Clinical and Economic Contexts Therapy is never practiced in an economic void. Economics determine what the system is willing to pay for and/or what the client can afford. However, you must avoid confusing economic and clinical decision making, The long used practice of"diagnosing up" so a client qualifies for insurance coverage is a good example of this. There is an ethical quandary in simultaneously working with clinical and economic realities. For example, is it ethical to tell a client with major depression, but no insurance coverage and only enough money for two sessions, to come back? Are you obligated to finish treatment with a client who runs out of coverage, even if it comes out of your pocket? When your sessions with a client are de-certified, do you terminate the patient or do you continue on at your own expense? When economics influence your delivery of care, the client must understand that economic, not clinical, considerations are involved. It is important to be concrete, specific, and accurate about the clinical results the client reasonably can expect to obtain, given the services that can be provided. If your best clinical judgment, augmented by the scientific literature, is that the client cannot reasonably expect to benefit from the amount of services that can be offered, it is imperative that you inform the client of your opinion. This introduces a serious fork in the road in terms of your ethics and sense of social responsibility. Is this the time to provide services ~pro bono" or should you refer the patient onto a (probably) less effective community resource? Fortunately, the

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author's experience is that this quandary rarely develops. In almost every case, achieving short term, positive behavioral goals is possible and, although the patient may not be able to undergo a "textbook" regimen of care, the client benefits from well focused, albeit limited, services. It is important to approach limited therapy goals, not with a defeatist attitude, but with the conviction you can work with client to make something positive happen. Mile-Post Seven: Be Flexible and Encourage Innovation Behavior therapists cannot allow the fear of health care reform to stifle willingness to be flexible in the way existing treatments are delivered or to innovate in ways that shake the traditional foundations of behavior therapy. The explosion of interest in the new "solution focused" strategic therapies suggests that the race is on for more efficient and effective ways to help clients (cf., DeShazer et al., 1986). A close look at most strategic approaches suggests that, although grounded in radically different assumptions about the process of change, they are profoundly behavioral in application. The attraction of these models is that they lead to ultra-brief, clinically potent interventions. In other words, it is becoming increasingly important to evaluate the possibility that major depression may be treated effectively in 4 to 6 sessions using behavioral approaches that do not explicitly follow the traditional cognitive or cognitive-behavioral paradigms. A recent study conducted at Group Health Cooperative highlights the potential of ultra-brief interventions (Strosahl, Romano, & Mason, 1993). Among a larger study sample of 487 out-patients, 51 patients were diagnosed at the initial interview as suffering from major depression. Independent and uninformed ratings of problem severity and coping adequacy were obtained from both therapist and patient at the point of entry into treatment, and ratings were repeated 4 months and 10 months after initiating treatment. Mean effect sizes for both patient's (d' = .92) and therapist's (d' = 1.19) ratings of clinical improvement at 4 months exceed those reported in meta-analyses of cognitive and behavioral treatments for depression (cf., Lipsey & Wilson, 1993). These outcomes were achieved using an average of 4.75 treatment sessions per episode of care. Critics of the strategic therapies rightly point out that there is little in the way of systematic clinical outcome research to justify the exorbitant claims made by their founders. Given the rapid proliferation of these treatments, why aren't behavioral researchers comparing strategic therapies with more standard behavioral treatments for index conditions such as depression, anxiety disorders, or childhood behavioral disorders? This kind of applied research will have a fundamental impact on the long term future of behavior therapy in the new frontier. If the strategic therapies prove to be more cost-effective than traditional behavioral approaches, radical behavior change principles need to be assimilated.

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Walking Through The Minefield It will be impossible to avoid contact with m a n a g e d mental health care systems. Because it is time to m a k e this journey, m a k e sure your destination is where you want to go; otherwise, you r u n the risk of e n d i n g up where you're headed! Each m a n a g e d mental health care setting has characteristics that m a y or m a y not fit your personal style. I n general, clinicians who choose to work in rural or u n d e r s e r v e d areas will have far m o r e latitude in d e t e r m i n i n g their practice style. Those who r e m a i n in u r b a n a n d s u b u r b a n settings will have to e n d u r e more intrusions. If you like a m a x i m u m a m o u n t of a u t o n o m y a n d prefer working alone, you will p r o b a b l y like participating in a Preferred Provider O r g a n i z a t i o n (PPO). This contractual a r r a n g e m e n t allows you to use an office practice model. Beware, P P O ' s use Utilization Review as a p r i m a r y m a n a g e m e n t strategy. Your practice style can be affected by telephone conversations with s o m e b o d y you've never met, who m a y or m a y not have the same professional degree you do. If you can tolerate this, you will be less at risk financially, as a steady stream of referrals will be directed to you, usually at a 10% to 15% discount o f f t h e going m a r k e t session price. I f you like to work a r o u n d other m e n t a l health professionals, you might like a staff or group m o d e l H M O setting. Usually, you will be salaried a n d work at a clinic o p e r a t e d by the group or the H M O . You won't have to deal with external U R companies because practice m a n a g e m e n t occurs at the staff level. Generally, you will be u n d e r pressure to see 4 to 6 new clients weekly a n d practice a less intensive style of individual therapy. T h e r e is also a heavy emphasis on g r o u p therapy and, in some settings, behavioral health services in medical settings. You need to be comfortable with the F a m i l y Dentist a p p r o a c h because that is the d o m i n a n t approach in H M O ' s . I f you are an entrepreneur, then consider j o i n i n g a capitated IPA ( I n d e p e n dent Provider Association). Your business group will be paid in advance to care for a certain base of consumers. I f you p r o d u c e good clinical outcomes in a cost efficient way, you stand to m a k e lots of m o n e y using an office practice model. M a k e sure you j o i n a group of practitioners you know a n d respect clinically. I f there are a couple of spendthrifts a m o n g you, you m a y lose m o n e y a n d end up selling real estate. I n general, be careful to review any organization, group, or network that has advertised for therapists. F i n d out how long the c o m p a n y has been in business. H o w m a n y "covered lives" does the c o m p a n y have u n d e r contract? H o w m a n y other providers are in the c o m p a n y a n d what is the p r o v i d e r mix? W h a t is the basic c o m p e n s a t i o n methodology? Beware of start-up H M O ' s , PPO's, and IPA's, because they frequently recruit therapists first, then go out and try to capture business. Meanwhile, you are sitting in your office waiting for patients who never come or a paycheck that never materializes. Be careful to follow the economic progress of your organization and be ready to make rapid adjustments.

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In the event you have an irreconcilable dispute with a managed care system, remember that it is regulated by the State Insurance Commission in any given state. This is a powerful avenue of recourse, especially if you can document a pattern of unfair business practices.

Key Mileposts In The Future There are many important issues behavior therapists individuaUy and as a group will have to address in order to capitalize on the managed care movement. First and foremost is the need to aggressively market the research efficacy of behavioral treatments in the form of "practice guidelines" Practice guidelines will eventually form the basis of managed care and, at this writing, are being strongly promoted by the federal government and managed care companies. It is important that these guidelines include the results of behavior therapy research. The often discussed gap between academic research and applied behavioral treatment may in part occur because "pure" versions of mental disorders appear less frequently in applied settings. Badly needed are field studies looking at the effectiveness of behavioral procedures with mixed diagnostic conditions, "V-codes" and patients with concomitant drug/alcohol problems. This will involve compromising some scientific rigor in order to gain generalizability. The next decade will witness an evolution/revolution in the mental health industry. Behavior therapists can lead the way into this new frontier and prosper, without losing their identity. Individually and organizationally, the focus needs to be on accepting responsibility for cost and quality, while remaining committed to shaping managed care practices over time.

References Armenti, N. (1991). The provider network in managed care. the Behavior Therapist, 14, 123-128. Armenti, N. (1993). Managed health care and the behaviorally trained professional, the Behavior Therapist, 16, 13-15. Austad, C., Sherman, W., & Holstein, L. (1993). Psychotherapists in the HMO. HMO Practice, 7, 122-126. Bennett, M. (1988). The greening of the HMO: Implications for prepaid psychiatry. AmericanJournal of Psychiatry, 145, 1544-1548. Berwick, D. (1989). Continuous improvement as an ideal in health care. New England Journal of Medivine, 320, 53-56. Bittker, T. (1985). The industrialization of American Psychiatry. American Journal of Psychiatry, 142, 149-154. Brill, E, Grissom, G., Howard, K., Malcolm D., & McClellan, T. (1993, January). COMPASS." Integra's outpatient mental health system tracking. (Available from Integra Inc., Radnor Plaza, 320 King of Prussia Road, Radnor, PA, 19087). Buie, J. (1987). Evidence of H M O flaws mounting. American PsychologicalAssociation Monitor, 18, 45.

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Chiles, J., & Strosahl, K. (in press). The suiddal patient: Ptindples of assessment, treatmentand casemanagement. Washington, DC: American Psychiatric Press. Cummings, N. (1986). The dismantling of our health systems: Strategies for the survival of psychological practice. American Psychologist, 41, 426-431. Cummings, N. (1988). The emergence of the mental health complex: Adaptive and maladaptive responses. Professional Psychology: Theory, Research and Practice, 19, 232-335. Cummings, N. (1991). Brief intermittent therapy throughout the life cycle. In B. Berman & C. Austad (Eds.), Psychotherapyin managedhealth care."The optimal use of time and resources(pp. 35-45). Washington, DC: American Psychological Association Press. Cummings, N., & Follette, W. (1968). Psychiatric services and medical utilization in a pre-paid health care setting: Part II. Medical Care, 6, 31-41. DeShazer, S., Berg, I., Lipchik, E., Nannally, E., Molnar, A., Gingerich, W., & Weiner-Davis, M. (1986). Brief therapy: Focused solution development. Family Process, 207-221. Dorwart, R., & Epstein, S. (1992). Economics and managed mental care: The H M O as a crucible for cost-effective care. InJ. Feldman & R. Fitzpatrick (Eds.), Managed mental health care:Administrative and clinical issues (pp. 11-28). Washington, DC: American Psychiatric Press. Fitzpatrick, R. (1992). The Harvard Community Health Plan: An evolving model of managed mental health care. InJ. Feldman & R. Fitzpatrick (Eds.), Managed mental health care."Administrative and clinical issues (pp. 385-399). Washington, DC: American Psychiatric Press. Howard, K., Davidson, C., O'Mahoney, M., Orlinsky, D., & Brown, K. (1989). Patterns of psychotherapy utilization. American Journal of Psychiatry, 146, 775-778. Howard, K., Kopta, S., Krause, M., & Orlinsky, D. (1986). The dose-effect relationship in psychotherapy. American Psychologist, 41, 159-164. Lange, M., Chandler-Guy, C., Forti, R,, Foster-Moore, E, & Rohman, M. (1988). Provider's view of H M O mental health services. Psychotherapy, 25, 441-448. Levenson, D. (1987). Toward a full disclosure of referral restrictions and financial incentives by prepaid health plans. New England Journal of Medicine, 317, 1729-1731. Lipsey, M., & Wilson, D. (1993). The efficacy of psychological, educational and behavioral treatment. American Psychologist, 48, 1181-1209. Manning, W., Wells, K., & Benjamin, B. (1986). Use of out-patient mental health care." 7?ial of a prepaid group practice versusfee-for-service. Santa Monica, CA: Rand Corporation. Mumford, E., Schlesinger, H., Glass, G., Patrick, C., & Cuerdon, T. (1984). A new look at evidence about the reduced cost of medical utilization following mental health treatment. American Journal of Psychiatry, 141, 1145-1158. Narrow, W., Regier, D., Rae, D., Manderscheid, R., & Locke, B. (1993). Use of services by persons with mental and addictive disorders: Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry, 50, 95-107. Phillips, E. (1985). A guidefor therapistsand patients to short term therapy. Springfield, IL: Charles Thomas Publishers. Rogers, W., Wells, K., Meredith, L., Sturm, R., & Burnam, A. (1993). Outcomes for adult outpatients with depression under prepaid or fee-for-service financing. Archives of General Psychiatry, 50, 517-525. Shoor, R. (1993). For mental health cost problems, see a specialist. BusinessandHealth, November, 59-62. Strosahl, K. (1991). Cognitive and behavioral treatment of the personality disordered patient. In B. Berman & C. Austad (Eds.), Psychotherapy in managed mental health care." The optimal use of time and resources(pp. 185-201). Washington, DC: American Psychological Association Press. Strosahl, K., Romano, E & Mason, C. (1993). A look at clinical outcome and patient satisfaction in an HMO." Results of the 7btal Quality 7?aining and Research Project. Workshop presented at the Group Health Cooperative of Puget Sound national conference, Leading The Way In Managed Mental Health Care: Innovative And Effective Strategies. Seattle, Washington, October.

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Taube, C., Burns, B., Goldman H., & Kessler, L. (1988). High users of outpatient mental health services: I. Definition and characteristics. American Journal of Psychiatry, 145, 210-213. Wells, K., Manning, W., & Benjamin, B. (1986). Use of out-patient mental health services in H M O and fee-for-service plans. Health Services Research, 21, 453-474. Wells, K., Stewart, A., Hays, R., Burnam, A., Rogers, W., Daniels, M., Berry, S., Greenfield, S., & Ware, J. (1989). The functioning and well-being of depressed patients: Results of the Medical Outcomes Study. Journal of the American Medical Association, 262, 914-919. Kirk Strosahl, Ph.D. is Staff Psychologist and Research Evaluation Coordinator for Group Health Cooperative of Puget Sound, the largest consumer owned Health Maintenance Organization in the United States, with a membership of 380,000 consumers in Western Washington. I would like to express my appreciation to Patricia Robinson, Ph.D. for her helpful suggestions regarding this paper. The comments and suggestions made by three anonymous reviewers also contributed greatly to the preparation of this paper. Requests for reprints should be directed to Kirk Strosahl, Ph.D., Group Health Cooperative, Central Region Mental Health Service, 1730 Minor Ave., Suite 1400, Seattle, WA, 98101. RECEIVED: September 1, 1993. ACCEPTED: February 9, 1994.