Managed Care Ethical Considerations Intro to Treatment Planning

1. Managed CareEthical ConsiderationsIntro to Treatment Planning

2. Class Overview • Class business • Introduction to managed care • Ethical considerations • Introduction to treatment planning

3. Introduction to Managed Care (MC) Lecture adapted from: Davis, S. R., & Meier, S. T. (2001). The elements of managed care: A guide for helping professionals. Belmont, CA: Wadsworth

4. Causes & consequences of MC • Deinstitutionalization… • Public outcry about “deplorable” conditions in asylums & state hospitals • 1955: Joint Commission on Mental Illness and Health- community alternatives to state hospitals • Due to costs, hospitals wanted to shift the financial burden to federal & local governments

5. Causes & consequences of MC • 2 significant events… • 1963: Aid to the Disabled (ATD) Act made mentally ill persons eligible for federal financial aid in the community • Now called Supplemental Security Income • Mental Retardation Facilities and Community Mental Health Centers Construction Act- federal grants for staffing newly constructed centers- implication that more programs would be offered (but not required in order to gain the funding!)

6. Causes & consequences of MC • The “social experiment” goes on… • 1965: introduction of chlorpromazine… Thorazine • Enactment of federal Medicaid & Medicare

7. Causes & consequences of MC • Lanterman-Petris-Short Act of 1968 (California) • Movement to get patients out of hospitals, to avoid violating their civil rights • Became more difficult to involuntarily commit patients • Federal & state facilities began closing down.

8. And then… • Patients discharged “to the streets” • Communities often didn’t have funding & other resources to administer care • Board-and-care homes & single-room-occupancy (SRO) hotels did not attract clients, nor provide long-term care… • And so, back to the streets.

9. And then… • Concept of the “least restrictive setting” • Jimmy Carter’s Commission on Mental Health: "the objective of maintaining the greatest degree of freedom, self-determination, autonomy, dignity, and integrity of body, mind, and spirit for the individual while he or she participates in treatment or receives services.“ • “psychiatric Titanic”… approximately 2.2 million severely mentally ill people do not receive psychiatric treatment.

10. And now… • Deinstitutionalization doesn't work. We just switched places. Instead of being in hospitals the people are in jail. The whole system is topsy-turvy and the last person served is the mentally ill person. -- Jail official, Ohio

11. Causes & consequences of MC • “a range of financial mechanisms and organized delivery systems which attempt to balance access, costs, and quality” (Stroup & Dorwart, 1997, p. 1) • Spiraling costs of care (esp. 1980s) • Outpatient costs steady • Inpatient costs skyrocketed • 1986 – 1990 MH/SA costs increased by average 50% • Reliance on inpatient treatment • Few incentives for efficiency/effectiveness

12. The basics • In theory… • Provide fixed set of services for fixed cost • Guarantee required services will be provided • Few people who have benefits use them • Costs for a few spread over many • But… • More people who are insured use benefits • Cost of what is covered has increased

13. Controlling costs • Have employer pay more • Charge more to use benefits (higher premiums/copayments) • Have fewer people use the benefits • Offer less coverage for the same price (cap annual or lifetime benefits)

14. Controlling costs • Reduce costs of the care itself • Restrict number of sessions • Reduce level of care • Use less expensive providers/pay less • Educate about prevention • Make wiser decisions about what to cover

15. Managed care foci • Medical necessity vs. quality of life • Reduce health care utilization • Increase productivity • Remove symptoms / restore balance • Establish definable goals and outcomes

16. Managed care foci in action • Reduce costs charged by the clinicians • Restrict services to those in need • Cap coverage and benefits • Participate in development of tx plan • Evaluate tx outcomes

17. Trends of MC services • Focused • Brief • Reduced inpatient length of stay • Supportive and coping-oriented • Focus on medication & compliance

18. Potential advantages of MC • Negotiates increased access to services • Wider variety of outpatient options • Standardization of care • Mandated documentation • Measurement of outcomes • More explicit community standard for malpractice determinations

19. Potential disadvantages of MC • Reduced direct-care resources • Incentives not to provide care • Increased administrative overhead • Negative impact on therapeutic alliance and treatment planning • Reduced provider autonomy • Malpractice responsibility

20. MC Survival Skills • UNDERSTAND THE SYSTEM • Wide variability in companies and benefits • Limits of coverage • “Allowed” doesn’t guarantee approval, and you can take that to the bank. Just not to the counselor. • Ongoing utilization review

21. MC Survival Skills • UNDERSTAND “MEDICAL NECESSITY” • DSM-IV diagnosis • Severity and functional impairment • Concrete impact on life, job, relations

22. MC Survival Skills • UNDERSTAND “MEDICALLY APPROPRIATE” • Definable goals and outcomes • Focused treatment plan with likely efficacy • Treatment matched to problem

23. MC Survival Skills • BUILD YOUR SKILLS • Focused initial assessment • Well-documented dx and impairment • Systematic differential diagnosis • Emphasis on measurable goals • Focused tx planning • Brief & crisis intervention skills • Comprehensive documentation

24. MC and the counseling process • Focused initial assessment • Pre-authorization or 1-session evaluation • Symptom description • Risk • Substance use • Psychosocial history • Mental health history & past treatment • Medications • Mental status

25. MC and the counseling process • Well-documented diagnosis and impairment • Comprehensive patient record • Checklist of symptoms • Use of structured interviews • Rating scales (self-report, clinician) • Computer programs

26. MC and the counseling process BUILD RELATIONSHIPS & PARTNER W/ CLIENTS • INVOLVE CLIENT in decisions and plans • Provide information about the disorder • Provide information about treatments • Provide information about managed care • Uncertainty of sessions approved • Confidentiality • Session frequency

27. Dealing constructively with MC Observations & Reactions • Establish a working relationship • Consultative • Respectful • Improve presentation skills • Remember case manager NEEDS information

28. Dealing constructively with MC • Develop clear goals and tx plan • Be meticulous with paperwork • Be assertive (not antagonistic/adversarial) • Appeal when necessary • Educate case manager • Work through the system

29. Managing Managed Care Ethics Braun & Cox (2005) Daniels (2001)

30. Ethical Issues Brainstorm

31. Ethical Issues • Informed consent • Confidentiality • Competence • Integrity • Human welfare • Conflict of interest • Conditions of employment • Client autonomy • Others…

32. Introduction to Treatment Planning Seligman (1998, 2004)

33. Why? “Treatment planning in counseling is the process of plotting out the counseling so that both counselor and client have a road map that delineates how they will proceed from their point of origin (the client’s presenting concerns and underlying difficulties) to their destination, alleviating troubling and dysfunctional symptoms and patterns and establishing improved coping mechanisms and self-esteem” (Seligman, 1993, p. 288)

34. Role of tx plans • Increase likelihood of success • Demonstrate accountability (MC) • Track progress & facilitate evaluation • Provide structure and direction

35. Early considerations • Client motivation • Client characteristics (action v. insight) • Nature of the problem (simple v. complex) • See Nelson’s (2002) “Counseling Strategy Selection Chart”

36. Diagnosis Objectives Assessments Clinician Location Interventions Emphasis Numbers Timing Medication Adjunct Services Prognosis Seligman’s DO A CLIENT MAP

37. DO A CLIENT MAPObjectives • Initial and ongoing • Mutual process • Foci • Improving subjective well-being • Reducing symptoms • Improving functioning • Should reduce DSM criteria/symptoms • Should increase GAF

38. DO A CLIENT MAP Objectives con’t • Describe problem specifically • Identify what needs to change • Observe Johnson’s Rule “A diagnosis can never be a problem statement, unless it is on Axis III, in which case it is always a problem statement”

39. DO A CLIENT MAP Objectives con’t • Make it measurable • Frequency • Intensity • Duration • Amount • Establish criteria • Identify time frame • Short, medium, long-term Make it Positive

40. DO A CLIENT MAP Objectives Practice

41. DO A CLIENT MAP Assessment • What additional data is needed? • How can we demonstrate effectiveness? • Remember, MC loves… • Checklists • Interviews • Rating scales

42. DO A CLIENT MAP Clinician • Which party/parties will provide services? • Consider • Experience • Training • Personal characteristics

43. DO A CLIENT MAP Location • Where will services take place? • What level/kind of care? • Consider • Nature, severity, progression, duration • Client functioning • Previous counseling • Logistics • Overall objectives

44. DO A CLIENT MAP Interventions • Theoretical framework • One guiding theory • Technical eclecticism • Specific strategies planned

45. DO A CLIENT MAP Emphasis • Level of directiveness and structure • Level of confrontation • Level of exploration

46. DO A CLIENT MAP Number of people • Individual counseling • Group counseling • Family counseling • Combination of the above

47. DO A CLIENT MAP Timing • Length of sessions • Spacing of sessions • Frequency of sessions • Duration / number of sessions • Time-limited?

48. DO A CLIENT MAP Medication • What is client currently taking? • Specifics • Side effects • Compliance • Refer for medication evaluation?

49. When? What? Who is responsible? Sequence of services? Skill development Focused counseling Personal growth Support groups Living arrangements Professional services Health-related Social/leisure orgs Governmental services DO A CLIENT MAP Adjunct Services

50. DO A CLIENT MAPPrognosis • Usual prognosis for diagnosis • Client characteristics/indications • Terminology: Excellent, very good, good, fair, poor, guarded