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MCIC Press Release

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Hot Off The Press

MCOs Lack Data on Value, Success of Outpatient Mental Care

Manasquan, N.J. -- Managed care organizations (MCOs) tend not to track return on investment (ROI) for use of outpatient behavioral healthcare benefits, according to a Managed Care Information Center poll.

They also either do not know or will not tell the following about their outpatient behavioral healthcare services:

* the percentage of recidivism;

* the percentage of successful treatment;

* the percentage of overall expenses; and

* the effect on medical and administrative loss ratios.

Although MCOs can monitor individuals’ usage of outpatient behavioral healthcare — and utilization is audited as part of the accreditation process — they tend not to aggregate and analyze data for financial or medical trends.

Also, MCOs that are able to track individual and group utilization say the extent of tracking depends on the enrollees’ plan.

WellPoint Health System can track some individual progress in an indirect way, such as looking at records for prescription refills, if the records are available through a WellPoint pharmacy, said Cheryl Noncorrow, who manages the MCO’s behavioral services.

Otherwise, the company can track general utilization from the volume of claims submitted by a physician or psychologist, and it can monitor general recidivism rates through quarterly statistics issued by the American Psychiatric Association, Noncorrow said.

No Universal Standard

The lack of data on outpatients’ progress points to the lack of one industry-wide standard to measure the effectiveness and value of outpatient behavioral healthcare.

Although there are accreditation measurements such as the widely used Health Plan Employer Data and Information Set (HEDIS) developed by the National Committee for Quality Assurance, even under such programs, outpatient mental health services are not necessarily audited for effectiveness.

HEDIS, for example, gauges effectiveness of mental healthcare only according to antidepressant medication management and follow-up after hospitalization for mental illness. The only way HEDIS measures outpatient behavioral healthcare is in terms of utilization, according to the percentage of plan members receiving services.

One MCO has its own system for measuring effectiveness of care. PacifiCare Behavioral Health, based in Laguna Hills, Calif., uses ALERT (ALgorithms for Effective Reporting and Treatment), a system that analyzes patient self-assessment data against the provider’s assessment of the patient to identify where the provider has not seen a risk.

It also enables management to see whether the provider is meeting the clients’ needs, program director Dr. Edward Jones told The Executive Report on Managed Care earlier this year (see the second issue of February 2001).

According to Jones, at the time, ALERT had analyzed more than 20,000 patient reports since 1999.

Feds Are Lax, Too

MCOs are not alone in the dearth of knowledge about behavioral health effectiveness and utilization. Interviews with representatives of the Centers for Medicaid and Medicare Services (CMS) and individual states revealed that state and federal agencies also fail to track and aggregate data regarding outpatient behavioral healthcare, although they contribute funds for such care.

Address: The Managed Care Information Center, 1913 Atlantic Ave., Suite F4, Manasquan, NJ 08736; (732) 292-1100,

For more information contact The Managed Care Information Center, 1913 Atlantic Avenue, Suite F4, Manasquan, NJ, 08736, toll-free telephone 1-888-THE-MCIC (1-888-843-6242), fax 1-888-FAX-MCIC (1-888-329-6242), e-mail or online at

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