Does type of gatekeeping model affect access to outpatient specialty mental health services?

Health Services Research, Feb, 2007 by Dominic Hodgkin, Elizabeth L. Merrick, Constance M. Horgan, Deborah W. Garnick, Thomas J. McLaughlin

Managed care organizations (MCOs) use a variety of strategies to influence the type, quantity, costs, and quality of health care that their enrollees use. Utilization management (UM) is one major approach that includes gatekeeping arrangements, preauthorization, and subsequent review of care. The application of UM to mental health care has proven controversial. Its potential benefits include improved appropriateness and cost-effectiveness of care; however, there are concerns about the basis on which decisions are made, the qualifications of reviewers, impact on confidentiality, and disruption of the provider-patient relationship (Tischler 1990; Zusman 1990; Miller 1996; Hennessy and Green-Hennessy 1997).

This article evaluates the impact of two different models of UM on the use of outpatient specialty mental health services within an MCO. In the first model, patients must be evaluated in person by a "mental health coordinator" before entering outpatient specialty treatment. In the second model, patients need only telephone a call center to receive routine preauthorization for the first eight outpatient visits to a specialty provider. We evaluate the impact of moving from the first to the second model, using data from a natural experiment that occurred in one division of Harvard Pilgrim Health Care (HPHC), a large mature MCO in New England. Our hypothesis is that the change in UM model improved direct access to specialty mental health, and should therefore have resulted in increased utilization of care. The hypothesis is tested by applying a quasi-experimental research design to administrative data from HPHC before and after the change, including comparison with another division that experienced no change in gatekeeping.

BACKGROUND

Much of the empirical research on the effects of UM of mental health care focuses on inpatient services. Most studies have found that some UM strategies are associated with lower costs and/or quantities of treatment (e.g., Gotowka and Smith 1991; Frank and Brookmeyer 1995; Wickizer and Lessler 1998; reviews by Hodgkin 1992 and Mechanic, Schlesinger, and McAlpine 1995; Wickizer, Lessler, and Travis 1996). A few studies have found only weak or no effects (e.g., Dickey and Azeni 1992; Eisen et al. 1995) or that effects are short-term (Frank and Brookmeyer 1995). Some findings have raised concerns about negative impacts on quality of care (e.g., increased rapid readmission rates reported by Wickizer and Lessler 1998).

Only a few published studies are focused on the effects of UM for outpatient mental health care. One study of UM procedures for initial and continuing care in outpatient behavioral health services in an HMO randomly assigned patients to receive a different allotment of initially approved visits and procedures to extend care: the experimental groups received six, 10, or 19 visits with automatic approval for extension up to 19 visits, and a control group received six visits and case-by-case review of treatment extension requests (Howard 1998). All experimental groups had significantly greater treatment lengths, and the groups with six and 10 initial visits used significantly fewer total sessions than the 19-visit group. These results suggest that both actual restrictions and simply the expectation of closer monitoring ("sentinel effect") affected outpatient utilization.

Liu, Sturm, and Cuffel (2000) report similar results from their study of preauthorization of outpatient mental health services in a specialty managed behavioral health care organization. Their study examined claims and authorization data for two groups of patients whose benefits--provided under employer carve-outs--were similar except in the number of mental health sessions initially authorized (either five or 10). Controlling for patient characteristics, patients in the five-visit group were about three times more likely to end treatment at the fifth visit than those in the 10-visit group. This was true despite the fact that approval of request for continued treatment was "almost guaranteed," supporting the concept of sentinel effects of UM.

Mintz et al. (2004) examined the association between a wide range of UM techniques and psychiatrists' treatment plan modifications (changes in frequency or number of visits, or type of treatment). The data source was a national survey of psychiatrists, who completed patient logs. After adjusting for patient, setting, and psychiatrist characteristics, it was found that patients who were subject to any UM were more than twice as likely to have their treatment changed as patients who were not subject to UM. Specific techniques that were significantly associated with treatment change were limiting referrals to selected hospitals or providers, financial incentives to limit referrals, and formulary restrictions, but not utilization review. The study design did not allow determinations regarding quality of care, but the authors raise the possibility of negative impacts because of the reported downward pressure on visits and importance of medication choices.