Scheffler Richard M.
School of Public Health, 405 Warren Hall, University of California-Berkeley, Berkeley, CA 94720-7360, USA.
J Ment Health Policy Econ. 1999 Mar 1;2(1):21-28. doi: 10.1002/(sici)1099-176x(199903)2:1<21::aid-mhp33>3.0.co;2-o.
Within the past decade, the mental health care system in the United States has undergone a significant transformation in terms of delivery, financing and work force configuration. Contracting between managed care organizations (MCOs) and providers has become increasingly prevalent, paralleling the trend in health care in general. These managed care carve-outs in behavioral health depend on networks of providers who agree to capitated rates or discounted fees for service for those patients covered by the carve-out contracts. Moreover, the carve-outs use a broader array of mental health providers than is typically found in traditional indemnity plans, encourage time-limited versus long-term treatments and favor providers who are engaged in outpatient care. This phenomenal growth in managed behavioral health care over the past decade includes the rapid growth and quick consolidation of mental health MCOs. The period 1992-1998 shows steady and substantial annual increases in the number of enrollees in mental health MCOs, the figure more than doubling from 78.1 million people in 1992 to a projected 156.6 million in 1998, or 70% of insured lives. Moreover, these vast numbers of enrollees are becoming increasingly consolidated into a smaller number of firms. In 1997, 12 companies controlled nearly 85% of the managed behavioral health care market, with 60% of the market held by the three largest firms. STUDY AIMS: This article reviews empirical data and draws policy implications from the literature on managed behavioral health care in the United States. Starting with spending and spending trend estimates that show the average annual growth rate of mental health expenditures to be lower than that of health care expenditures in general over the past decade, the author examines utilization and price factors that may account for managed-care-induced cost reductions in behavioral health care, with special attention to hospital use patterns, fee discounting and the supply and earnings patterns of various types of mental health provider. In addition, data on staffing ratios and provider mixes of health maintenance organizations and mental health MCOs are reviewed as they reveal at least part of the dynamics of reconfiguration of the mental health work force in this era of managed care. CONCLUSIONS: As measured by changes in utilization and price, widespread application of "classic" managed care techniques such as preadmission review (gatekeeping), concurrent review, case management, standardized clinical guidelines and protocols, volume purchase of services and fee discounting appears to have led to significant cost reductions for providers of both impatient and outpatient mental health services. However, amidst a complex flux of market variables such as risk shifting, changing financial incentives and intensity of competition, not all of the reduction or slowdown in spending can be clearly and purely attributed to managed care. The data on the ongoing reconfiguration of the mental health work force are clearer in their implications: with an oversupply of all types of mental health providers, managed care has significant potential to increase the incidence of provider substitutions and spur the growth of integrated group practices. IMPLICATIONS FOR FURTHER RESEARCH: The current body of empirical and policy literature in mental health economics suggests several salient areas of follow-up. Is the proportionately greater impact of managed care on the annual growth rate of mental health care spending a temporary phenomenon or does it signal an enduring difference in the rates of increase between behavioral health care and health care in general? Beyond industry downsizing, what are the substitutions among mental health providers that are going on, and will go on, to produce cost-effective practices? What are the new financial or risk-sharing arrangements between providers and MCOs that will produce appropriate and high-quality mental health services?
在过去十年中，美国的精神卫生保健系统在服务提供、融资和劳动力配置方面经历了重大变革。管理式医疗组织（MCO）与提供者之间的签约越来越普遍，这与整个医疗保健领域的趋势一致。这些行为健康方面的管理式医疗分割业务依赖于提供者网络，这些提供者同意为分割合同所涵盖的患者提供按人头付费率或折扣服务费。此外，分割业务所使用的精神卫生提供者种类比传统的赔偿计划中通常所见的更为广泛，鼓励限时治疗而非长期治疗，并倾向于从事门诊护理的提供者。在过去十年中，管理式行为健康护理的这种显著增长包括精神卫生MCO的快速增长和迅速合并。1992 - 1998年期间，精神卫生MCO的参保人数每年稳步大幅增加，这一数字从1992年的7810万人增加了一倍多，预计到1998年将达到1.566亿人，占参保人数的70%。此外，这些大量的参保人正日益合并到数量更少的公司中。1997年，12家公司控制了近85%的管理式行为健康护理市场，其中最大的三家公司占据了60%的市场。
本文回顾实证数据，并从关于美国管理式行为健康护理的文献中得出政策含义。从支出和支出趋势估计开始，这些估计表明在过去十年中精神卫生支出的年均增长率低于总体医疗保健支出的增长率，作者研究了可能导致管理式医疗在行为健康护理中降低成本的利用和价格因素，特别关注医院使用模式、费用折扣以及各类精神卫生提供者的供应和收入模式。此外，还审查了健康维护组织和精神卫生MCO的人员配备比率和提供者组合数据，因为它们揭示了在这个管理式医疗时代精神卫生劳动力重新配置动态的至少一部分情况。
以利用和价格变化来衡量，“经典”管理式医疗技术（如入院前审查（守门）、同期审查、病例管理、标准化临床指南和方案、服务批量采购以及费用折扣）的广泛应用似乎已导致住院和门诊精神卫生服务提供者的成本大幅降低。然而，在诸如风险转移、不断变化的财务激励和竞争强度等复杂的市场变量变动中，并非所有支出的减少或放缓都能明确且纯粹地归因于管理式医疗。关于精神卫生劳动力持续重新配置的数据在其影响方面更为清晰：由于各类精神卫生提供者供应过剩，管理式医疗极有可能增加提供者替代的发生率，并刺激综合团体执业的增长。
精神卫生经济学领域当前的实证和政策文献表明了几个值得后续关注的突出领域。管理式医疗对精神卫生保健支出年均增长率的影响相对更大，这是一个暂时现象，还是标志着行为健康护理与总体医疗保健在增长率方面存在持久差异？除了行业规模缩减之外，正在发生以及将会发生哪些精神卫生提供者之间的替代行为，以形成具有成本效益的做法？提供者与MCO之间将产生适当且高质量精神卫生服务的新财务或风险分担安排是什么？
