[Congressional Record Volume 144, Number 24 (Tuesday, March 10, 1998)]
[Extensions of Remarks]
[Page E335]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




  MANAGED CARE AND MENTAL HEALTH/SUBSTANCE ABUSE: A NATIONAL DISGRACE

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                        Tuesday, March 10, 1998

  Mr. STARK. Mr. Speaker, managed care does many things will and some 
things poorly. It has been my impression that its major failing lies in 
the area of mental health and substance abuse services--and the 
following report submitted to the Congressional Budget Office in 
October 1997 by J. Wrich & Associates, Inc. (JWA) confirms that 
impression.
  The report, which describes a pattern of lying about services, 
malpractice, and profiteering at the expense of some of the sickest in 
our society, is a call to action. As we consider managed care consumer 
protection and quality legislation, we need to provide special 
protections in the mental health and substance abuse sectors.
  In the coming weeks, I will be proposing legislation to address some 
of the issues so well-raised by the Wrich report. Portions of this 
report follow:

                   A. OVERSTATED PROGRAM UTILIZATION

       There was a tendency with providers audited to overstate 
     utilization. In some instances multiple patient numbers were 
     assigned to the same patients. One provider issued a new case 
     number each time it authorized additional care. In other 
     instances, case numbers were assigned on an annual basis, 
     thereby enrollees were counted more than once if they 
     received services in two or more calendar years.
       In one audit the utilization reported by the contractor to 
     the customer was: 5085 patients.
       The audit found utilization to be: 3495 patients.
       Variation--overstated utilization reported vs. actual: 45%.


                        B. TIMELINESS OF SERVICE

       J. Wrich & Associates has consistently found timeliness of 
     service to fall far outside the contractors' written 
     standards.
       Typically the contractor's written standards fall within 
     the following parameters:
       Routine cases shall receive service within 5 days;
       Urgent cases shall receive service within 24 hours;
       Emergency cases shall receive service within 2 hours.
       This computes to a blended average standard for elapsed 
     time of 4.32 days.
       Actual performance in audits JWA has conducted ranged from 
     8.5 to 19.3 days.
       Variation--Contractor's written standards computed to a 
     blended average vs. the blended average of actual waiting 
     time for care: 97% to 347%.


                         C. NETWORK DEVELOPMENT

     Coverage
       Coverage is frequently spotty. Where managed behavioral 
     health care serve employee groups in multiple locations, JWA 
     finds considerable unevenness in provider network development 
     and accessibility. In the case of one managed behavioral 
     health care company serving a statewide enrollee group, the 
     contractor's proposal and initial agreement called for a 
     minimum of one chemical dependency and one mental health 
     provider in each county. Two years into the contract, gaps in 
     the provider coverage were found to be as follows:

------------------------------------------------------------------------
                                                   Counties    Enrollees
                                                      not         not
                    Findings                        covered     covered
                                                      (%)         (%)
------------------------------------------------------------------------
No providers at all.............................          15           6
No mental health providers......................          16           7
No substance abuse providers....................          32          19
No adolescent/child providers...................          25          12
------------------------------------------------------------------------

       In this case, the customer paid the full premium for 100% 
     of the plan's enrollees during that time frame even though 
     the managed behavioral health care network was never 
     completely in place to serve all of them.
     Matching Service to Enrollees' Problems
       JWA found that provider networks are rarely developed with 
     adequate consideration of expected high incidence of certain 
     disorders. Two landmark studies of incidence and prevalence--
     the Epidemiologic Catchment Area Study and the National 
     Comorbidity Study--indicate that as many as 80% of the adult 
     population with a behavioral health disorder have one of four 
     major diagnosis or some combination thereof--substance abuse 
     disorders, major depression, anxiety, and phobia. None of the 
     managed care companies JWA audited have built their networks 
     on a research-based rationale of expected patient needs.
       Contractor reports on employing minority providers are 
     often overstated. One ploy involved hiring high percentages 
     of Asian and Indian providers who were anxious to build their 
     practices and willing to work for lower fees, as opposed to 
     employing established African Americans providers who would 
     have more closely profiled the culture and ethnicity of the 
     target population.


                           D. CLINICAL ISSUES

       JWA found the charts they have audited to reveal a 
     surprisingly high percentage of problems across the full 
     spectrum of service.

------------------------------------------------------------------------
                                                                Problem
                          Findings                            charts (%)
------------------------------------------------------------------------
Failure to properly evaluate/diagnose/treat substance abuse   54.8-78.3
 cases where a diagnosis of a substance abuse disorder was
 documented in the chart, or where there were strong
 indications of the presence of a substance abuse disorder..
Failure to properly evaluate/diagnose/treat psychiatric       4.3-8.6
 disorders cases where a psychiatric disorder was documented
 in the chart or where there were strong indications of the
 presence of a psychiatric disorder.........................
Failure to follow up........................................  6.3-78.8
Instances in which a patient had not received care within     4.1-26.0
 three months of initial contact due to delays in
 authorization or due to other administrative/clinical
 problems...................................................
------------------------------------------------------------------------

                        E. ADMINISTRATIVE ISSUES

       The frequency of administrative problems which had an 
     impact on the delivery of care varied widely among providers. 
     Problems included delays in answering telephone inquiries, 
     failure to authorize care in a timely manner, problems with 
     payment of claims.
       Total Problems of Cases: 37% to 86%.


                     F. PATIENT PLACEMENT CRITERIA

       JWA audits have shown that the criteria for inpatient, 
     residential, or intensive outpatient treatment is often 
     extremely restrictive. In one audit the provider required an 
     attempt to harm self within the previous 24 hours, or 
     significant action or harm to another person within the 
     previous 24 hours, or significant threatening action to 
     damage property with high lethality in order to receive 
     intensive outpatient care or inpatient care.
       Another audit revealed that the criteria for admission to 
     detoxification services put the patient at risk because it 
     included a confirmed diagnosis of addiction plus the presence 
     of delirium tremens. Most experts would agree that a major 
     purpose of detoxification is to prevent DT's, which are life-
     threatening medical conditions.
       Mr. Speaker, the J. Wrich & Associates report causes great 
     concern. While the audit findings cannot be generalized to 
     the entire managed care industry, several audits performed by 
     this company since 1992 have found significant problematic 
     similarities in placement criteria, practice guidelines, 
     network development procedures, and pricing among many of the 
     firms. Currently patients have little protections against the 
     bad mental health care that they often receive.
       In the near future, a large number of us will be 
     introducing a Patient Bill of Rights to provide new 
     protections in managed care. Some of the provisions of that 
     bill will help stop the type of abuses and abysmal care 
     documented by the JWA audits. I suspect, Mr. Speaker, that 
     the problems in the mental health and substance abuse sector 
     are so severe, that we will need separate, special 
     legislation to address this sector's unique problems. I am 
     working on such legislation and welcome ideas and suggestions 
     from the provider and patient communities.

     

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