Managed Care: Influencing Care of Mentally Ill through Managed Care Essay

The provision of health care to persons all around the globe is a challenge that has been existent for quite some time now. The basic right of human health has been denied to many, either due to poverty illness, or economic issues, to increased costs and discriminations due to race, nationality, ethnicity and so many more irrelevant issues. The point of the matter stays where it has been for so long now; that healthcare to all is still a mission that has a long way to go.[1]

 

Although for health care issues that are related to the body have enjoyed some progress, support, funding and awareness, same cannot be said for patients who suffer problems and illnesses pertaining to the mind. Indeed the issue is one of concern, as statistics have shown up to 450 million people to be suffering from neurological and psychiatric diseases around that globe. What is more, such persons cannot avail health care opportunities, even if they are in the position to do so. The problems lie in the lack of resources and availability of facilities, even in developed countries, the lack of awareness that people have regarding psychiatric and mental illnesses.[2]But most of all, the biggest contributing and the most detrimental factor is the discriminatory attitude that these patients suffer due to their condition. The patient is unable to receive any medical attention for the fear of being “labeled” but also is afraid of the consequences that he or she may suffer due to the condition. For such persons are one of the most targeted groups of hatred, discrimination, violence, abuse, poverty, human rights violations, and economic isolation.[3]

 

The statistics are very grim. It is a fact that only half of the people around the world have primary care access for the treatment of their mental conditions, and many are unable to afford the treatments. The parity between the physical and mental health is extremely biased, and very small proportions are given to the mental health care system. There are no alternative care systems, and the services show a “paternalistic care” service to the patients. [4]

 

The still low priority given by health policy makers around the globe regarding mental health is a sad realization of the fact that this issue still has a long way to go before it is taken seriously. It is however important to highlight some of the efforts that have been instituted worldwide to promote mental health care provision. WHO has introduced the concept of mental health advocacy where by families of mentally ill patients are given the chance to make their voices heard.[5] Advocacy however, is only one part of the total mental health policy programs that WHO has introduced. Such programs are mainly aimed to increase awareness, and reduce discrimination that people with mental illnesses face. The results of these collaborative effects have started to show results, and now many policy changes are taking place around the globe to address the needs of mental health care provision.[6]

 

Managed care in the recent years has become one of the most contributory institutions in the provision of health care. It is now with time showing promise in the provision of mental health care to public. With more and more efforts and policies being formulated, it is hoped that managed care will be able to provide state of the art mental health care facilities.

 

There are however, many problems that are present in the present managed care system. Although managed care may have been helpful in its early stages in the provision of care, but with time and the introduction of new players, it has become a case of economical savings. The provision of health care is slowly becoming a second priority. These problems reflect the problems that now loom over the medical sector. Without addressing these issues, it is very hard to expect any contributory role of managed care in either physical or mental health care.

 

Managed care is expected to play a significant role in the provision of mental health care; however, due to the above mentioned problems and those that will be discussed in the ensuing chapters, it becomes very difficult to predict what positive roles managed care can play should these issues be resolved.

 

The thesis is therefore aimed to address these issues in a formulated manner. The thesis is aimed to briefly describe the problem of mental illnesses and the different global statistics and findings related to the condition. It aims to bring to notice the negligence that has been carried out in the provision of care to such patients. It also aims to study the various issues and problems that surround and complicate mental illnesses, such as the stigma and discriminatory attitudes in society, public and healthcare systems, and the global lack of interest around the world about treating patients with mental illnesses.

 

Beginning with this theme, the thesis will then review the different efforts taken around the world in relation to provision of mental health care in various health care provision systems. It looks at the role that WHO has played in promoting and addressing them. It will define managed care and how it came to be, what differences and changes have taken place throughout the years, and specifically will address the role that managed care has, can and will play in the provision of mental health care. It will address the parity and equity issues that face the managed care in relation to mental health care and will detail elaborately on the process of utilization review, its different components and the different issues that is presents with regards to managed care.

Managed care is one of the most important healthcare sectors in the UK. It is hoped that the thesis will be able to identify the role that managed care can have in the provision of mental health care in UK health care system, and be able to clarify the issues that need to be addressed in order to ensure the provision of such.

 

Specifically, the whole discussion of the components aims to answer one question. Does utilization review influence the delivery of healthcare? And if so what are the pros and cons that this system has demonstrated in the provision of quality care?

 

 

 

 

 

 

 

 

 

 

 

CHAPTER 2: MENTAL ILLNESS AROUND THE WORLD: GLOBAL STATISTICS

MENTAL ILLNESS IN THE USA: STATISTICS

Mental health issues are one of the most prevalent causes of illness, even more so than asthma. WHO has demonstrated that out of 10, 4 of the leading causes leading to disability in persons 5 years and older are mentally related.[7]  15 percent of the global burdon diseases comprise of mental disorders. One in six persons shows some type of mental illness at one stage of their life. In America, this prevalence is one in every five persons. 630,000 people at one time may show severe mental illness, which could be of a wide range. The people who are affected are mostly the family members, who constitute over 1.5 million carers.[8] More than 10 million Americans display co-existant substance related and mental health disorders.[9]

Fifteen percent of the adult population use some form of mental health service during the year. Eight percent have a mental disorder; 7 percent have a mental health problem. Twenty-one percent of children ages 9 to 17 receive mental health services in a year.[10] The year 1996 demonstrated expenditures of $99 billion related to mental illnesses.[11]

 

The health care services in the United States have been increasing gradually with no signs of letting up. The estimates in the 1990s showed that the healthcare services cost an annual of $660 billion. This was roughly equivalent to 12 percent of the gross national product. The predictions of the increase rate were estimated to be 12 to 15 percent each year. The more disturbing fact in all this was the meager allocation that was given to mental health services, which was only 12 to 14 percent of the total allocation.[12]

 

The analysts have been adamant that in mental health care has been under extreme danger due to the discriminatory allocations managed care has given it. Mental service allocations among the psychiatric ailments included other issues such as alcohol abuse and drug abuse. The portion that these services got was naturally very appalling.[13]

 

 

 

 

 

 

 

 

 

CHAPTER 3: ADVOCACY IN MENTAL HEALTH

The biggest challenge that a mental healthcare faces is justify that mental health care provision is as important as the provision of physical healthcare. There are many problems that the mental health care sector is battling with. Many countries of the world face deficiency of mental healthcare institutes, along with poor and appalling conditions of provision of care in them.  These have been compounded with the prohibitively high costs of the treatments, the parity issues among the mental and physical health, and paternalistic services with virtually none alternative services and the lack of acknowledgement of the patient’s right to self determine.[14]

 

Perhaps one of the reasons that mental healthcare has not been able to assert itself is the relatively unpredictable outcome of the treatments carried out on the patients.[15] Many of the cases of mental illness, and particularly cases of extreme, have shown almost no results when treatment was given. This not only led to frustration among the patients themselves, but also among the family members and the caretakers of the patients. The treatments that mental healthcare require are usually expensive, with almost no support from the insurance companies, leading to an increased cost expenditure that may not be affordable for the patient. This point has been one of the weapons many people have placed in front of the supporters of mental health care, by producing statistics of success rates in physical illness related treatments. This point of argument unless proven otherwise, will continue to haunt the advocates of mental health care systems.[16]

 

All of the above problems have been extensively documented by WHO throughout the years. WHO claims that only half of the total world’s population has access to mental healthcare, but its efficacy is questionable. 40% of the mental healthcare financing is out of pocket type. This is compounded by the fact that about 40% of the countries around the world consist of no mental health policies. [17]

 

Other challenges that the mental health care faces is the need to integrate community participation in it, and promoting the various aspects of mental health care in different social settings such as schools, colleges, workplaces etc. mental healthcare is very insistent on acquiring government support by introduction of various health policies and programs, so as to remove the social stigma, bias, discrimination, and human rights violations that such individuals suffer from.[18]

 

The barriers to accessing mental healthcare is now one of the most debated topics amongst the mental healthcare providers. Many have contributed in creating awareness about the issue, and one of the contributors is David Mechanic.[19] David in many of his works has highlighted the problems faced by individuals in need of psychiatric treatment. In many of the studies that he has cited, he has come to a conclusion that many of the individuals surveyed do need mental health care provision, but do not seek it. He also cited studies that showed that only half of the patients in need for immediate mental and psychiatric treatment do in fact get it. The other surveys demonstrated less than 50 percent of the patients get the treatment they are so in need of.[20]

 

When the surveys asked the patients the reasons for not seeking treatment, many insights were received. Patients were not willing to call their symptoms a mental disorder, and even those who were receiving treatment, refused to call their condition as so. This was in part of the patients’ insistence of having good social relations with good standards of life. However, they did admit to having issues with the perceived stigma of mental illness, low self esteem, and depression and depression like symptoms. Other factors that were influential in the seeking of care included the patient’s own mental attitude about mental treatment, affects on marriage and comorbid physical conditions. Females were seen to show a more interest in seeking treatment than males, and these were significantly increased if the patient had good insurance plan, or who had some family history of related illnesses.[21]

 

In these studies Mechanic stated that more than 40 percent of the patients believed they could handle the situation themselves. Similarly half of the people did not consider their condition to be in need of treatment. Up to 40 percent did not seek treatment due to the increased cost of the treatment. Many did not know where to seek treatment, how effective the treatment was, or how convenient or inconvenient it can be.[22]

 

There are many contributors to advocacy in mental health care, and these range from the consumers and their families, to non governmental organizations, general health and mental health workers, and policy makers and planners. Each contributor provides a unique perspective in dealing with the challenge, and therefore each is a major player. By cooperating with these players, the governments around the world aim to help in dealing with this issue.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER 4: EHTICAL ISSUES

The most worrying part in the whole scenario is the consistent negative attitude that has been demonstrated around the world regarding mental health. There are many form with which it has been demonstrated, which include stigma, discrimination, isolation, deprivation and desolation, and perhaps the most concerning of all, violence and human rights violations.

 

Stigma can be defined as “something about a person that causes her or him to have a deeply compromised social standing, a mark of shame and discredit.”[23] This leads to many negative emotions and reactions being thrown at the persons affected by mental illnesses, and in turn they may have to face isolation and negativity. It is usually thought that persons of mental illness may show laziness and lack of intelligence, and may demonstrate violent, uncontrolled, and unpredictable behaviour patterns. This leads to many problems in their social life, as they are considered irresponsible and beyond hope of treatment. Such stigma makes them unable to carry out actions that would prove them other wise, prevent them in getting high tanks and standards in life, and achieving lasting and deep committing relationships.[24]

 

The stigma leads to many changes in one’s personality that may not have been evolved in cases of isolated mental illness. The fear of being discriminated in such fashion makes the patients reluctant and even unwilling at times to seek treatment. The person may become isolated, which in turn further reduces one’s self image and self esteem, and denial of normal legal procedures such as loans, jobs and housing become out of reach for such patients. Under such circumstances, the person may in fact have more complications arising in his mental state.

 

With time managed care has come to encompass and represent a wide variety of health care institutes which may operate on different principals. The application of ethical principles become difficult due to the diversity in managed care. However, if managed care is to be taken at its core value, without modifications or additions, the outlining of the ethical issues can be made simpler. Although managed care was aimed to give a solution and alternative to fee-for-service, it still needs to go a long way to achieve that. Of these the primary ethical issue of concern is the denial or limitation of the services that is given to a patient, and the long cumbersome process that denials entail. The only silver lining that can be understood is that denials and limitations can be applied to almost any one, regardless of the social or economical status, and regardless the necessity of the treatment. [25]

 

The above argument may contain some merit, as it is impossible for any government to provide all types of care to any one without setting of some restraints in the budgets and allocations. But of more concern is the quality of care that may be affected through the application of managed care and utilization reviews. This argument is fully discussed in the subsequent pages. The main point however, is that concerns over compromising health of patients is hardly a comforting thought. [26]

 

The second disturbing argument is the limitation managed care causes in the access of care. Limitation can be defined in the sense that care might be given to the most deserving. This may in fact be not such a bad idea, as giving unnecessary access may lead to wastage of the health care facilities, leaving the more needy patients behind. This question is more of concern in mental health care, where it is argued that only the most affected individuals be given treatment. What problems this can lead to is discussed later, but what is certain is that limitation may not be a good idea until or unless special circumstances come into play.[27]

 

But of all the arguments that may come out against managed care, none is perhaps more worrisome than the effects that managed care can have on the patient and practitioner relationship. With the introduction of review processes, doctors are forced to limit care in more than one instance. With the addition of incentives, the doctors are being motivated to do so more by the insurance companies. With the increased hold of these companies, the doctors are in most instances, forced to make decisions that may not be in the best interests of the patient. This is compounded by the insistence of the managed care to seek the services of particular health care providers, regardless of the inconvenience it may cause to the patient or the significant danger a life can be put to. Doing less for more is perhaps one of the most dangerous methods of cutting costs, and many lives are at stake, like the many that have gone before them. in order to get a treatment approval, the physicians are forced to divulge confidential information of their patients, which may also compromise the doctor patient relationship.[28]

 

Consent obtaining becomes a more difficult and technical area in mental managed health care, as the patients may or may not be in the correct state of mind due to their psychiatric illness. This issue in one form or the other is continuously under debate and rules need to be very clear and very explicit in defining terms of consent.[29] The issue of parity in relation to this is also discusses in subsequent chapters.

 

Another ethical issue that has come to attention is the amount of hold that managements and insurance companies have in the decision making process. This is not only a concern for the patients, but also a concern for the doctors, who are expected to do less for more, and in this manner are forced to take decisions that may not be entirely in the benefit of the patient.[30]

 

 

 

 

 

 

 

 

 

CHAPTER 5: THE HISTORY AND DEVELOPMENT OF MANAGED CARE

The field of health care has grown in to a multifaceted institution addressing many areas of health care. These include the actual provision of the health care to the patients and disposal of medications, the methods through which health care is provided, the different levels of health care provision as well as the professionals involved in its provision, and lastly the various policies and interventions that are continuously shaped and reformed to curtail to the needs of a wider public with special emphasis of individualized care.[31]

 

The concept of managed care goes back to the nineteenth century, and aimed essentially at the patients of the rural areas and professionals pertaining to the “lumber, mining and the railway industry.”  The pioneer of this method is Dr. Shadid, who in 1929, despite much resistance was successful in carrying out health care delivery in return for a fixed fee to families mentioned above. Other honorable mentions of the time include Dr. Donald Ross, Dr. H. Clifford Loos and Dr. Sidney Garfield. All of these physicians worked in collaboration with various unions and state departments to provide care for the labor as well as their families of the departments.[32]

This concept has continued itself in the form of “capitation” where the physician or a health care provider is given a fixed fee in return for his or her services to a group of people, sometimes with some discounts.[33]

 

The method of care delivery was straightforward, both the parties, that is the doctor and the patient decided on a payment amount as per the type of treatment or health care facility being provided or received. These payments in turn were either paid through self or through the interventions of a social society, depending upon the case. The approach was highly appreciated and therefore widely applied. This concept later on became the foundation of the modern managed health care. One of the main reasons for its success stemmed from its low fee.[34]

 

The system was at this time quite a simple one. As times changed more and more innovations and developments took place. Many ideas were borrowed, included and modified in the different stages of its development. One of the most significant was the application of this program during the World War II, when Henry Kaiser set up two major health care programs on the West Coast to provide health care services to workers of the shipyard and steel mills. Kaiser later on expanded this program to include the general public as well, making it for the very first time a public service rather than confined to one or two entities.[35]

 

His initiative was followed by Group Health Association, the AeroMechanics Union and many others. Each of these followed mostly on the principals of Henry Kaiser’s model, especially the incentive that his program was a prepaid program of group practice. Henry Kaiser is the pioneer of the prepaid health care currently used in the whole world.[36]

 

Many significant differences would be seen in these older versions if compared to today’s managed programs. For example, the care facilities were mainly controlled by its owners with very little influence of the subscribers. Indeed in many of these cases, the costs of health care were higher than their counterparts. Yet even though these areas displayed the some what negative issues of the facilities, there were more incentives to it. The level of care provision was a wholistic one in the sense that it did not mainly focus on providing therapeutic or symptomatic care, but rather a health care service that included preventive, outpatient, pediatric and immunization services as part of the basic health care facilities. Here lied the true advantage point of these managed cares and the reason why people despite the higher cost opted for them.[37]

 

The resistance and the counterattacks this system had to face came in various forms. The introduction of the crude and primitive form of independent practice association is one of the prime examples of the tactics and strategies employed to compete with the managed care concept. Along with it the managed care had to face fierce resistance from organizations up to and including the American Medical Association itself. The concepts of “corporate practice, lay control and prepaid plans” was the basis of differences in opinions. The resistance by AMA led to its conviction of violating the Sherman Antitrust Act, however, even this did not prevent the considerable damage managed care had to bear through the hands of  AMA.[38]

 

This bleak picture of managed health care remained till the late sixties and early seventies, when the Nixon government started inviting and accepting alternative methods of quality health care delivery to the masses. The efforts led to the formation of the first Health Maintenance Organizations, which aimed to provide loans and grants to these services as well as removing bans that were impeding the development of this new and unique health delivery system.[39]

 

The different transformations and events in the history of managed care include the contract medicine care of which the Shadid case is the example, third party administrations, the Blue Cross and Blue Shields in the 1930s, Kaiser Health plans, and Medicare and Medicaid.[40]

 

The system became known for its economical yet “comprehensive” health care delivery curtailing a large group.  The success was evident by the fact that the per capita spending on health care from 1965 had risen from $198 to $336 in 1970.[41] With the passage of time is showing increased numbers with regards to health care systems as well as the number of enrollees.[42]

 

Within the last five years managed care has come from the back to the front line in the provision of health care services. The services include the model health maintenance organizations as well as preferred provider organisations. The shift and the trend have taken place mainly due to the “market forces, regulatory initiatives and the customers’ demands” and with it the rising number of patients enrolling and benefiting from the Medicaid health service.[43]

Although the managed care system started as a single entity, it divided itself into various multiple services in meeting the demands of the continuously growing health care system. The Health Maintenance Organisations were further divided in to staff, group, network and IPA, whereas the other MCO models included the Preferred Provider Organizations (PPO), Point of Service (POS), Exclusive Provider Organization (EPO) and Physician Hospital Organisations (PHO). The difference between the different HMOs laid in the employment of Health Care Professionals, multi specialty physician groups and contracts with one or more such entities, and contracts with independent community based physicians and group practices.[44] With the advancement of the managed care system, many issues surfaced. The most prominent of these issues involved the escalation of the health care costs. The increase came as a result of “advancements in medicine and its technology, labor costs, specialist physicians, care provision for the uninsured, indigent and the increased population burden.”[45]

In the modern terms managed practice refers to a “system of care and techniques of integrating payment and delivery methods in to the general clinical behavior of the providers excluding or including the patients.” It aims to provide a cost effective solution to health care services while maintaining “quality, cost and access”.[46] Though managed care may have shown many positive aspects, there are many areas which require more scrutiny as well as planning. The issues that have been risen with time are not small, and include not only the ethical component of this type of service, but also the type of effect such practice may have on the patient physician relationship.[47]

Ethical concerns arise simply from the demand from the physicians or the health care providers must give “more with less”.  That is they must try to reduce as much unnecessary procedures as possible with increased amount of input with less utilization of sources. While this strategy has been backed up with incentives such as bonuses for the physicians in response to compliance, it has the downside effect that the level of care given and the time spent on each patient may be considerably reduced, which in turn could adversely effect the physician patient relationship. The situation can be further complicated with the result that the patients may start to show distrust in the system due to the above mentioned factors. [48]

The cost of provision of mental health care in managed care has become an issue of concern for many. With the new figures showing the increased burden mental health care puts on the US system, the debate between supporters and adversaries intensifies.[49]

 

Some of the other issues that were raised in the 80s and 90s were related to the limited choices patients had in choosing providers and in opting for institutes and providers of preference. Also included was the lack of benefit coverage, and ethical and the cost effectiveness component discussed above.[50]  Managed care in the 80s and 90s showed a very productive era in mental health care services. Many programs were introduced at this time which included alcohol and drug addiction treatment programs and psychiatric programs for adolescents among the many. The adverse effects of this all too quick promotion was evident very soon, when analysts were able to prove the misuse of such services by the public and the institutions, without benefiting much. In the light of such evidences, these services were later cut down by reducing the treatments and long stay at the hospitals.[51]

 

The above mentioned steps led to an outbreak of controversies and debates, for many physicians were of the view that introduction of above mentioned healthcare in the mental division may lead to more harm than benefit. The opponents very soon were able to prove the same, when they demonstrated the rejection of mental healthcare in outpatient and inpatient clinics, increased co-payments, and utilization of non psychiatric personnel for mental healthcare provision.[52]  There were other reasons why this turmoil rose. The history of ignorance of mental healthcare provision, the resistance of the insurers to include mental healthcare as an equal part to physical healthcare, and the limits on care provision and increased costs of the treatment all pointed to the bias that mental healthcare had faced. Such steps were a comeback signal for the physicians who had worked so hard to come to this point of getting mental healthcare recognized as an integral part of healthcare provision.[53]

 

The list doesn’t end here. In its prime, the managed care only curtailed people and patients who had the necessary resources to avail these health care systems. Managed care and its physicians did not prefer handling Medicare programs for the fee costs in this system were very low. Only the elderly Medicaid programs had fee costs matching private fee, and this was the only Medicaid area that received full acceptance from the health care providers. Similarly, managed care system did not prove to be very helpful for people who did not have resources to undertake health insurance coverage. Due to this, these people were left with no choice but to avail those resources that were in reach for them.[54]

 

Managed care proved to be a hard pill for the physicians too, as working for such institutes meant working under their employers. This in turn meant that the health care decisions did not lie in the hands of the physicians any more but rather the employers. This in turn meant that the physicians lost the liberty to actively participate in the health care policy matters, with the key players being the employers of such managed care systems.[55]

Prior to the HMO bill, the insurance sector was gradually expanding itself in both the private and the public sectors. The insurance sector decreased worries for the patients regarding their health care costs, which in turn led to increase in the prices of services curtailed by the health care providers. The overall effect showed a sharp increase in all areas of health care costs, private, public and state and federal. Another effect that was observed was that this increase in cost was carried out with little government or market interference.[56]

With the introduction of the HMO bill, many changes took place. The HMO in the bill was given power in many sectors like growth and development and power. This then was followed by the Omnibus Budget Reconciliation Act or OBRA which conferred increased flexibility for Medicaid patients with regards to payment for care. The physicians and the consumers were given limited choices regarding choice of provider and practice.  The final event was the passing of the TEFRA or Tax Equity and Fiscal Responsibility Act in 1982. This acted permitted HMOs to carry out contracts with organisations like Medicaid on the “risk basis”.[57] For Medicaid, this was somewhat of a life saving action, as Medicaid from its conception had not faced any significant prosperity period. Medicaid was faced with issues such as “financing and coverage, lagging provider participation, and appropriate access and service use for covered beneficiaries.”  This strategy, in combination with “provider backlash in the private sector” and “tradeoffs associated with managed care in exchange for the value these models provide to the beneficiaries and purchasers”, has led to many improvements in the Medicaid in the recent years.[58]

The bills and the reforms showed increased and positive response on the public sector health care. But the private sector was faced with different challenges. 1980s was the time of severe recession in the American economy, which led to deductions in all areas of services, including the Medicaid. This negatively affected the health insurances as they became the prime target to cut costs.[59]

But private care has shown some attributes that put it in a favorable light when compared to public health systems. These systems are able to provide a more comprehensive one to one relationship to the patient. The access to patient’s records, clinical information and patient trust are added features of this program’s favorability. This is in contrast to public sector, which shows flaws, and has difficulty in coordinating and sharing patient information with other physicians and facilities.

With the above mentioned issues pertaining to managed care, it is not so difficult to see why it has gained so much controversy. While some physicians state the managed care practice to be “jeopardizing the patient physician relationship”, others view it as an opportunity to increase breadth in the overall provision of health care without undermining the relationship. [60]

It must be observed that the impact of managed care on academic medicine can be counterproductive. With increased market demand and federal debt, less emphasis is now being placed on research. This in turn is turning academic areas a training grounds for managed care and how to work in them, rather than addressing the negative effects it is creating on the academic standards and the students learning systems.[61] The integration of managed care has shown a positive impact in the overall health care programs. With the help of information systems, financial incentives and other features such as shared culture, HMOs have helped in improving and influencing the practice patterns of health care systems and facilities. The pay for performance incentive given to hospitals has been introduced to promote better health care among the providers, in turn improving the overall health care scenario. The overall result demonstrated in the clinical trials points that “evidence based practice improves clinical outcomes.”[62]

 

Public managed care in many cases led to the closure of hospitals and shifting of patients to the Medicaid. Massachusetts is one of the prime examples of such cases, where patients started obtaining services from general hospitals instead of the state hospitals. While shifting patients to Medicaid may have solved problems like expenditures, it led to other problems like discontinuity in the treatments of the patients leading to increased lengths of hospital stays. However, such changes help in assessing and formulating new strategies to address the issues. In the case mentioned above, it was deduced that if the patients were given a specific institute to cater to their needs, it would help in better follow up record maintaining. The patient would then become the responsibility of that particular institute or institutes. [63]

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER 6: PROBLEMS FACED BY MANAGED CARE REGARDIGN MENTAL HEALTH CARE PROVISION

The parity issue is one of the major issues that are faced by the mental healthcare in managed care system. The managed care policies in the past have been very discriminatory toward mental health care facility, where only a small proportion and at times even negligent amounts were allocated to mental health care provision. The parity legislations in health care were motivated on account of the shamefully low insurance coverage given to mentally ill patients. The parity issue has now been much resolved with the introduction of newer health care plans. And with increased awareness, even the health care providers choose to work for companies and organisations that give them more liberty in decision making.[64]

 

The most significant of the parity legislations was the 1996 Mental Health Parity Act, which aimed to emphasize the removal of discrimination against mental health provision and increasing the budget allocation of mental health care.[65] The 1996 MHPA was able to get rid of many issues that faced mental health care sector. More comprehensive parity provisions were introduced, even to the point of full parity. Plans that in any way burdened the mental health care provision were discouraged. Although the parity laws were introduced in 1996, no actual benefits were to be seen until after 1998. This phase became much more difficult for mental health care seeking patients, where they were discouraged to do so. It was in 2000 that it was realized that parity laws although included were not implemented properly. It meant that simply passing the law was not going to ensure mental health care provision and in order to do so, more efforts will be required. The 1996 parity law, was soon to be reintroduced in the form of Mental Health Equitable Treatment Act in 2001, which ensured no limitations on the treatment or financial requirements for mental health of the insured. The prohibitions and the limitations that were previously present in the provision of mental health care were removed, and different forms of deductibles, such as coinsurance and co-payments were removed.[66]  This increase in the mental health care facilities was at first a big concern for the insurance companies.  Upon the introduction of the 1996 MHPA, the companies acknowledge no significant increase in the costs of health care provision

 

Parity gives many benefits to the mental health care management. The financial risk that mental healthcare delivery posed for the patient was one of the leading discouraging factors in seeking treatment. With the removal of this factor, it is hoped that more patients will take part in seeking treatment.  The insurance function that was in many ways lost was restored.[67]

 

 

 

 

 

 

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CHAPTER 7:UTILIZATION REVIEW PROCESS

Utilization review has become a normal process of assessment in the current health care system. It has shown improvement in providing appropriate and timely health care service to incidences of work related illnesses or injuries. It improves communication within the health care system and thereby provides a quality health care to the patient. In the United States of America, this system has become integrated in nearly all of the health care systems, whether public or private[68].

 

Utilization review can be defined as “any review of the medical necessity, appropriateness, or efficiency of medical services, done on the behalf of the hospital or health care benefit plan.”[69] The utilization review aims to provide the most necessary of health care services to the patients while at the same time identifying and denying health procedures that are either unnecessary or irrelevant to the case. The trend has fast taken shape as a result of the increasing costs per annum of the health care services. With more and more players in the health care provision process, the system of simply the doctor deciding the treatment for the patient and authorizing it has become almost obsolete.

 

Now a days, a health care provider is forced to act based on the decisions of the health care policies and the insurance companies. With the introduction of managed care, the situation has become a mixed picture of success and failure.

 

The success can be attributed to the fact that managed care and the utilization review process have indeed led to much reduction in the excessive use of resources on unnecessary procedures.  However, the political implications have become the voice of concern and the issue of debate in the public. The public of the United States has gradually come under the impression that by implementing the utilization review process, they have been robbed of the choice to be provided with the health care that they deserve.

 

Recent studies have also contributed in strengthening the case of utilization review process in the managed care. Fick (2001) and colleagues in their study researched the amounts of unnecessary or inappropriate medicine in patients under managed care. The study was aimed to bring to notice two important areas of managed care utilization. Firstly, it aimed to show that patients were at increased risk of getting inappropriate medication while under managed care. This is a cause of concern as a large number of the reported complications and treatments are due to inappropriate use of medicine and correcting the negative effects of them. Secondly, the study aimed to highlight that by the help of utilization review procedures, managed care will be better able to handle costs and utilization that is seen when inappropriate medication delivery takes place. The retrospective study reviewed patients aged 65 and over under the managed care, and evaluated among other things, the costs and inpatient and outpatient utilizations, number of prescriptions, and the patient demographics. The results were able to prove the increased use of inappropriate medication in these patients, leading to high utilization costs.  [70]

 

Some of the cases may be genuinely ones that are requiring unnecessary treatments and procedures. But what of the others who may have a genuine need for a treatment and have been denied it? The questions have created much restlessness among all areas of health care personnel, who feel that they have to become choosy in approving and authorizing treatments for some and not the others. The providers voice the concern that it may be jeopardizing the level of care they may be providing to the patients, with the resulting consequences of further deterioration of the situation. Utilization review has become a much heated issue, with no completely satisfactory answers for any side.

 

But before creating a negative image about the system, one has to identify the reasons why utilization review was made and what are its aims and objectives. The review has been made to meet the objectives of cost reductions within the health care system by eliminating unnecessary and inappropriate treatment. Other objectives are to provide the physicians the responses in time for authorizations regarding patient treatments and procedures. The review also aims to improve the level of communication between the medical community and the state fund.[71] The aim, according to the state, is not to deny services, but to better utilize the services to those in the most need. The system believes that any improvements in the health area cannot take place unless unnecessary expenditures are saved and put to better use. The concern is not limited to costs only; it involves the human provider’s element as well. The increasing demand of function and performance had always been asked from the medical community, without understanding its issues and grievances. This has resulted in reduced performances in the health care providers in all sectors. The aim is to reduce the stress and the constantly increasing demands on the providers, by giving them patients with more needs.

 

The numbers of interventions that are carried out under the utilization review are very variable, and are therefore categorized based on the type of the case under review.

Prior to utilization review many programs were available to curtail to the needs of people with disabilities. In conjunction with the utilization review, the state fund has now introduced and implemented the Return to Work Program. This program helps patients with early interventions and promotes early returning to work, along with transitional duties, and in doing so reduces the temporary disability costs.[72]

 

The procedure of utilization review is usually carried out by the intervention of a third party, which can be internal or external. An internal party is commonly the insurers or the health plans, where as the external parties can be independent groups who render their services in return for profit.[73]

 

The procedure of the utilization review process usually begins with an application made by the health care provider to the insurance or health care company indicating the kind and type of procedure required for the patient. This report is based on the first visit of the injured person to his or her physician and the general physical examination and history of the patient. This is termed as the request for authorization. The request is both oral and written in pursuance to Labor Code Section 4610(h) on the form “Doctor’s First Report of Occupational Injury or Illness”.[74]

 

These applications can then be categorized as common condition problems or otherwise. When a case of common condition appears, the claims adjuster is given the authority to authorize it. But where other treatments that is outside of this category come into play, they are to be sent for Utilization Review.[75]

The application received then goes into the hands of the reviewer, a person mostly the licensed health care provider who studies the case and evaluates whether the procedures and the medical treatments contain any issues that need to be looked in to, and “if these services come under the scope of the reviewer’s practice.” [76]

 

Two types of reviewers are present, the DONC or the District Office Nurse Consultant and the DOPT, or the District Office Physical Therapist. The applications made by these personnel are then documented with reasons why the particular case has been approved or disapproved.[77] The decision made can then be either accepted, withdrawn, delayed or denied. In all the cases proper written documentation as well as reasons for any of the actions must be clearly stated. And any advice on the matter might be given. The claim can then be modified, which explicitly means carrying out or approval of a treatment or procedure that are apart from the ones made on the written application.[78]

 

The review conducted can be of different types. Preadmission reviews are responsible for authorization of patient admission in a hospital as well as the amount of the time he or she will spend there. Usually these cases rarely get denied.[79]

 

A concurrent review is one which is carried out while the patient is admitted in the health care service. It reviews applications of extensions of hospital stays and decides on accepting or rejecting them. When viewed from the cost effectiveness point of view. These reviews have shown a 5-10% reduction in the overall number of visits in the hospitals.  An expedited review defines one which must be carried out in urgency or the patient may be at risk of losing his or her life, limb or may have serious morbidity associated with late intervention. [80]

 

Retrospective reviews study the abstract data and patient information to assess for reimbursement claims. These assessments can verify the authenticity of the procedures carried out on the patients and based on them can either accept or deny the claims. This area has been deemed unpopular since many claims do get denied in the eyes of the patients, though for hospitals this means less costs and easing of sampling. The problem with this review is that there is no effective method of verifying these claims as they are dependant on the hospital records, the quality of which may vary from good to extremely bad.[81]

 

One of the recent additions has been the ambulatory care review. This review was formulated keeping in mind the rising costs of health care and plans. The patients are evaluated for their problems and then referred to a provider. Studies demonstrate low numbers of denials in such cases, and the inclusion of additional expenses such as drugs and medical equipment.[82]

 

The application and the procedure if approved becomes “authorized” meaning “the assurance that appropriate reimbursement will be made for an approved specific course of proposed medical treatment to cure or relieve the effects of the industrial injury.”[83]

 

Denials usually take place on the account when an application does not fulfill the standard criteria of the state department. For this the department holds the right to “revoke, suspend or restrict a certificate or waiver and/or impose monetary penalties”. This makes it clear that the requirements of the application are very strict and require the complete compliance of the act, along with its policies. Also the requirements state that examination can be carried out by the director if he or she deems it necessary. The act however, allows the applicant to make a written request regarding the decision to the Department once it gets “denied, revoked, suspended, limited or restricted within 30 days of the decision”.[84]

 

Denials are mostly handled by the medical directors, who aside from handling such cases; also oversee cases of denials involving intensive treatments. They handle appeals related to denials too.[85]

This procedure is most commonly termed as grievance, and is used to reverse any decision that has been given regarding a particular case. Denials are also covered in this area.

 

This area has become a crux of problems in many ways. One of the most affected people apart from the patients in the issues of denials is thought to be the health care providers or the doctors. First, the doctors may be forced to reduce the number of authorization cases so as to keep up to the utilization review standards. Secondly, the doctors may feel frustrated at having to go through the excessive and time demanding paper work that utilization review curtails. The denials, in this way become more of a hassle than a positive experience.[86]

 

 

 

 

 

CHAPTER 8:UTILIZATION REVIEW STANDARDS
The utilization review standards have been formulated with the observation in mind that the inefficient use of resources within the medical hospitals and health care organisations is responsible for the increased cost and expenditure in the health care system. With the introduction of this process in almost all areas of health care, it is aimed that these problems will be identified and reduced.[87]

 

Utilization reviews work on many levels of provision of health care. They may review applications that have been submitted for the first time, conduct reviews which can be concurrent or retrospective or other types, and may also look at cases that have been amended, denied or have been filed for reconsiderations. All these reviews require separate guidelines and reviewers are required to be well versed in all these areas.

 

Many things need to be considered to implement these standards in the utilization review process, and to apply the process. For example, it is imperative that the healthcare services should have a clear idea about the total quality management, what it is and how to apply it successfully to an institution. To increase this awareness means increased efforts in providing ongoing education. The areas of health care that come under the utilization review process are large, and include the not only social and diagnostic services, but also emergency services. With the division of the tasks of the departments within them selves, the efficiency of the system gets better, and with constant dialogue, the teams are better able to tackle the situations that come their way. [88]

 

More focus is now on making utilization review a part of the organization rather than an external influence. By doing so, an increased sense of accountability to self is created, along with the increased in the quality of care and quality and conservation of resources.[89]

 

The utilization review standards have been formulated by the American College of Occupational and Environmental Medicine. And the guidelines are termed as the ACOEM practice guidelines. The second edition of these guidelines became effective in 2004 and set various criteria for the process. The utilization review plan requires the full credentials and contacts of the medical directors involved in the plan who hold unrestricted licenses for practicing medicine in the different cities of the United States. Also required is the detail of the procedures carried out to review requests and the methods of authorizations and decisions regarding these requests.[90]

 

The plan also insists on the directors to provide them with the specific criteria that they employ when carrying out the utilization reviews. These may also include the treatments and standards and the different processes involved with them. The director must ensure that any requests or written applications made should be following the criteria of the ACOEM guidelines, and the treatment schedule that he or she devises is in accordance with the Labor code section 5307.27. [91]

 

Other requirements include the submission of the qualifications and roles of the different personnel who are part of the review process, descriptions of the claims administrator’s practice and related areas, the compliance of the various review processes with the Labor code section 4610. The guidelines require the presence of a non-physician and a physician reviewer, who will, within their capacities are able to provide authorizations and discuss the applicable criteria for various cases, as well as addressing and handling various “specific clinical issues” that may arise in some of the cases.[92]

 

All these requirements must be fulfilled before authorization is given to carry out the utilization review process. Once these criteria are fulfilled, the actual plan comes into work.

 

When the actual process begins, it begins with the review meetings arranged on monthly basis focusing on one area in particular. Many cases come into the review at this time, but the most significant ones include those treatments that were aborted by the patients themselves before the decided time, or cases whose inpatient treatments spanned either less than a month or more than 90 days. Other areas included may be waiting lists or complicated cases involving more than one jurisdiction.[93]

 

Out of the cases, 8 are randomly selected. These cases must be fulfilling the subject criterion and the selection becomes the responsibility of the program’s technician, a degree holder of psychology, along with the help of a medical records personnel. The first part of the review involves the medical records personnel to evaluate the adequacy of the charts selected for second stage review. The selected charts then are evaluated by the technician with the director of research and evaluation, who then based on the information available, decide whether the patient will benefit from and deserves the treatment suggested for him. The charts passing this criteria move forward for the third level of review, which is conducted by the member of the utilization committee review.[94]

 

The procedure of reviewing these cases, especially the second and the third level reviews, are a combination of two systems that were devised by Yale and Rockland projects. Both of these criteria were later on unified to form a comprehensive review guide. While the Yale system evaluated the adequacy of the review process through a series of yes/no questionnaires, the Rockland project based its objectives on the provision of basic health care, primarily mental health. These were combined to form a checklist which addressed 24 objectives and gave a rating on a 7 point scale. Charts that are able to fulfill the criteria are accepted, recommendations added if required, and this becomes the patient’s final recommendation. [95]

 

The concept of accredition in the utilization review process is not a new one. Developed in the 1980s, this process aimed at reducing differences in the working standards of different health care systems so as to promote a unified set of standards which is followed through. Accredition mainly means a process “by which a partial organization will review a company’s operations to ensure that the company is conducting business in a manner consistent with national industry standards.” [96]

 

The area not only covers the utilization review processes, but also case managements and health plans etc. the process helps in addressing important issues of health care delivery, by involving all the parties involved in the health care system. These include the patients, the employers, the health care professionals and organizations, and insurers, regulators and legislators. The process ensures the provision of many rights to the different parties. To a consumer, it ensures the patient appeal process. It makes them realize the state of the health care systems and the efforts being placed to improve them. It also helps them in placing their suggestions for improvements in the system. [97]

 

Before 1998, the managed care system displayed many flaws in the system. For example, patients were required to refer to specific health care providers and settings to avail their health care benefits. This fear of denial of health care coverage in other health care settings caused people much morbidity and mortality, as they would in the most severe conditions; attempt to reach their own health care services. Another issue of concern was that the patients were mostly categorized and segmented to the different health care providers, and access to other providers was limited. This resulted in patients being denied the right to go to a practitioner of their own preference. Access to specialty care was not addressed adequately. Sudden switches in health plans left patients vulnerable, and clinical trials were not addressed. Lastly issues like prescription drugs availability and accessibility to health care services, along with discrimination issues made the patients and the consumers very agitated. [98]

 

The 1998 Patient’s Bill of Rights Act reduced many of these issues of the patients. For example no authorization was required prior to the emergency cases. Also the patients were given the liberty to access any health care provider they felt like. The patients were also given specialty care services. The transitions from old health care plans to new ones were made to take place smoothly. The patients were provided with adequate provider network, and terms were set not to discriminate patients on the basis of their race and ethnicity.[99]

 

The variations that are mostly seen in these cases are mostly the lack of uniformity in the processing. The confusion it has led to among the physicians either comes from services of prospective review, or from following the different guidelines and criteria for authorizations of treatments. The variable set of criteria among the claims administrators becomes a concern as then the types of care received would become dependant on who the claims administrator is and what are his or her criteria in the matter.[100]

 

The need to reduce variability therefore lies in providing evidence based guidelines to follow rather than the “proprietary guidelines” that have been in use up till now.[101] By doing so, more uniformity can be achieved in the utilization review system.

Utilization Review Standards
The utilization review standards have been formulated with the observation in mind that the inefficient use of resources within the medical hospitals and health care organisations is responsible for the increased cost and expenditure in the health care system. With the introduction of this process in almost all areas of health care, it is aimed that these problems will be identified and reduced.[102]

 

Utilization reviews work on many levels of provision of health care. They may review applications that have been submitted for the first time, conduct reviews which can be concurrent or retrospective or other types, and may also look at cases that have been amended, denied or have been filed for reconsiderations. All these reviews require separate guidelines and reviewers are required to be well versed in all these areas.

 

Many things need to be considered to implement these standards in the utilization review process, and to apply the process. For example, it is imperative that the healthcare services should have a clear idea about the total quality management, what it is and how to apply it successfully to an institution. To increase this awareness means increased efforts in providing ongoing education. The areas of health care that come under the utilization review process are large, and include the not only social and diagnostic services, but also emergency services. With the division of the tasks of the departments within them selves, the efficiency of the system gets better, and with constant dialogue, the teams are better able to tackle the situations that come their way. [103]

 

More focus is now on making utilization review a part of the organization rather than an external influence. By doing so, an increased sense of accountability to self is created, along with the increased in the quality of care and quality and conservation of resources.[104]

 

The utilization review standards have been formulated by the American College of Occupational and Environmental Medicine. And the guidelines are termed as the ACOEM practice guidelines. The second edition of these guidelines became effective in 2004 and set various criteria for the process. The utilization review plan requires the full credentials and contacts of the medical directors involved in the plan who hold unrestricted licenses for practicing medicine in the different cities of the United States. Also required is the detail of the procedures carried out to review requests and the methods of authorizations and decisions regarding these requests.[105]

 

The plan also insists on the directors to provide them with the specific criteria that they employ when carrying out the utilization reviews. These may also include the treatments and standards and the different processes involved with them. The director must ensure that any requests or written applications made should be following the criteria of the ACOEM guidelines, and the treatment schedule that he or she devises is in accordance with the Labor code section 5307.27.[106]

 

Other requirements include the submission of the qualifications and roles of the different personnel who are part of the review process, descriptions of the claims administrator’s practice and related areas, the compliance of the various review processes with the Labor code section 4610. The guidelines require the presence of a non-physician and a physician reviewer, who will, within their capacities are able to provide authorizations and discuss the applicable criteria for various cases, as well as addressing and handling various “specific clinical issues” that may arise in some of the cases.[107]

 

All these requirements must be fulfilled before authorization is given to carry out the utilization review process. Once these criteria are fulfilled, the actual plan comes into work.

 

When the actual process begins, it begins with the review meetings arranged on monthly basis focusing on one area in particular. Many cases come into the review at this time, but the most significant ones include those treatments that were aborted by the patients themselves before the decided time, or cases whose inpatient treatments spanned either less than a month or more than 90 days. Other areas included may be waiting lists or complicated cases involving more than one jurisdiction.[108]

 

Out of the cases, 8 are randomly selected. These cases must be fulfilling the subject criterion and the selection becomes the responsibility of the program’s technician, a degree holder of psychology, along with the help of a medical records personnel. The first part of the review involves the medical records personnel to evaluate the adequacy of the charts selected for second stage review. The selected charts then are evaluated by the technician with the director of research and evaluation, who then based on the information available, decide whether the patient will benefit from and deserves the treatment suggested for him. The charts passing this criteria move forward for the third level of review, which is conducted by the member of the utilization committee review.[109]

 

The procedure of reviewing these cases, especially the second and the third level reviews, are a combination of two systems that were devised by Yale and Rockland projects. Both of these criteria were later on unified to form a comprehensive review guide. While the Yale system evaluated the adequacy of the review process through a series of yes/no questionnaires, the Rockland project based its objectives on the provision of basic health care, primarily mental health. These were combined to form a checklist which addressed 24 objectives and gave a rating on a 7 point scale. Charts that are able to fulfill the criteria are accepted, recommendations added if required, and this becomes the patient’s final recommendation. [110]

 

The concept of accredition in the utilization review process is not a new one. Developed in the 1980s, this process aimed at reducing differences in the working standards of different health care systems so as to promote a unified set of standards which is followed through. Accredition mainly means a process “by which a partial organization will review a company’s operations to ensure that the company is conducting business in a manner consistent with national industry standards.” [111]

 

The area not only covers the utilization review processes, but also case managements and health plans etc. the process helps in addressing important issues of health care delivery, by involving all the parties involved in the health care system. These include the patients, the employers, the health care professionals and organizations, and insurers, regulators and legislators. The process ensures the provision of many rights to the different parties. To a consumer, it ensures the patient appeal process. It makes them realize the state of the health care systems and the efforts being placed to improve them. It also helps them in placing their suggestions for improvements in the system. [112]

 

Before 1998, the managed care system displayed many flaws in the system. For example, patients were required to refer to specific health care providers and settings to avail their health care benefits. This fear of denial of health care coverage in other health care settings caused people much morbidity and mortality, as they would in the most severe conditions; attempt to reach their own health care services. Another issue of concern was that the patients were mostly categorized and segmented to the different health care providers, and access to other providers was limited. This resulted in patients being denied the right to go to a practitioner of their own preference. Access to specialty care was not addressed adequately. Sudden switches in health plans left patients vulnerable, and clinical trials were not addressed. Lastly issues like prescription drugs availability and accessibility to health care services, along with discrimination issues made the patients and the consumers very agitated. [113]

 

The 1998 Patient’s Bill of Rights Act reduced many of these issues of the patients. For example no authorization was required prior to the emergency cases. Also the patients were given the liberty to access any health care provider they felt like. The patients were also given specialty care services. The transitions from old health care plans to new ones were made to take place smoothly. The patients were provided with adequate provider network, and terms were set not to discriminate patients on the basis of their race and ethnicity.[114]

 

The variations that are mostly seen in these cases are mostly the lack of uniformity in the processing. The confusion it has led to among the physicians either comes from services of prospective review, or from following the different guidelines and criteria for authorizations of treatments. The variable set of criteria among the claims administrators becomes a concern as then the types of care received would become dependant on who the claims administrator is and what are his or her criteria in the matter.[115]

 

The need to reduce variability therefore lies in providing evidence based guidelines to follow rather than the “proprietary guidelines” that have been in use up till now.[116] By doing so, more uniformity can be achieved in the utilization review system

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER 9:GOALS OF UTILIZATION REVIEW

There is no doubt that the utilization review has become one of the most debatable issues in the medical sector. Whether it is about the policies that have fabricated the system to the different confusions and speculations revolving around these policies, utilization review has been in the social and political limelight for quite some time now.

 

In order to understand the problems surrounding this system, one must be able to understand the goals, aims and ideals that were put forth to fabricate this system. by doing so not only will be able to understand the factors that are its prime foundations, but also be able to analyze and compare as to how much we have achieved in reaching these goals.

 

Utilization review aims mainly to reduce the ever increasing demands of health care sector by promoting strategies that reduce expenditure, while at the same time provide results that are of the highest quality. With the governments aiming to include more and more people into the health care system, more energy and resources are required to address them and provide them with the services. However, more people mean more personnel, more facilities, and more medications, all at the same or better health care delivery level. With growing expenditures in all areas of the health care sector, there is a need to consolidate our resources and to channel them so that more effective results are gained with fewer resources.

 

Meanwhile, the utilization review aims to pinpoint and identify any faults or short comings in health care facilities currently providing utilization review services, and aims to increase the level of care by instituting guidelines, protocols and checks and incentives on these services.

 

The guidelines have already been mentioned in the previous chapters. Proper following of them is essential if a provider seeks to give his patients the necessary approvals for the services and treatments. And this is why it is required that all providers working under the utilization system be able to comprehend the different aspects of utilization review, and be able to work in accordance with them. Without the correct and through knowledge, a practitioner will never be able to convince the directors and committees in the approval of treatments for his or her patients.

 

The implementation of utilization review also aims to produce a uniform system of health care system, which works under the same standards, and thereby ensure the quality of same standard across the entire health care system.

 

 

With time more and more demands have been made by the consumers in the provision for a better medical health care system. The areas that are under scrutiny involve “the efficiency, the effectiveness and the quality of the U.S health care system.”[117] The issue does not simply involve the doctors or the health care providers; it involves all areas of services which are involved in delivering quality health care. It is for this reason more and more efforts are being placed to promote and improve these areas.

 

Managed programs are faced with this challenge more as it is required to provide quality health care services at reduced costs. This means that they are required to put maximum use of their resources with minimum of expenditures. The proper utilization is thought to improve the inflating prices of health care which continue to grow on a yearly basis.[118]

 

So what models should be regarded as the best models which are able to accurately follow the utilization review systems and policies, while at the same time giving satisfactory care to the consumers. The system of chronic care model comes to mind. This model was founded by Ed Wagner, who believed that chronic care takes place not in the hospitals but outside them, meaning that a large part of chronic care takes place when the person is not hospitalized. This can either be in the form of self management, information systems and decision support systems and community resources. Chronic care management is mainly the domain of disease management systems and the health plans as very few systems outside of these are capable of handling it. The results, albeit limited, have already started to show that this system could indeed be the answer to our health care problems, including financially and clinically, achieving criteria.[119]

 

When studying the clinical and financial outcomes, more and more data is gathering which is essentially favoring these case management programs. The statistics have shown approval among the public as well, which can be seen through the increased number of enrollees each year in to these programs. Another trend that has been shown to support the system is the use of evidence based medicine. The need is to further improve the results and while doing so maintain them.[120]

 

The utilization review process aims to address many of the social goals of the U.S. government. Of these, it mainly wants to reduce the fear of patients that by going to a health care provider or a system means losing financial security. It also aims to provide preventive care, disease management and prevention.

 

The concept of limited care has been highly misunderstood. Limited care means that the patients should be given the amount that is appropriate and essential for them, but not that is excessive. For example, if a patient recovers in the hospital stay before his or her appointed date of discharge, and no detrimental effect will happen should he or she leave, then there is no harm done in doing so.

 

What is required however that is a system of proper follow up and care should be maintained so that should any emergency arise, it could be handled immediately. Many of the inpatient cases are cases of chronic conditions like diabetes and hypertension etc. The aim should be to help and educate these patients in realizing their condition and ways to improve themselves, while at the same time have regular checkups in their primary care facilities. This would reduce the number of complications arising due to chronic conditions, as appropriate follow up and health care is provided nearer to the patient, along with reduced incidences of emergency hospital admissions. All these will automatically lead to reduce efforts and hours put in by the health care staff, thereby reducing overwork and shortage of staff. Less hospital expenditures will be spent on health incidences that were completely preventable, while providing care for more important cases. By this method the use of hospital resources will be carried out in a more appropriate way.

 

But what is the effect of managed care and utilization review on a doctor or a health care provider. Current policies and reviews have not put doctors in a vulnerable position; they have also bound them into making decisions based on the policies of the state laws, the insurance companies, the reviewers and administrators and so forth. Previously, the treatment decisions were made only by doctors, with least amount of interference from outside sources. Now the situation has reversed. Providers are forced to take sides for either the patients or the reviews. Where taking the patient’s side, the provider may lose credibility with the utilization review. On the other hand, taking the review’s side may mean the provider may have to make less than perfect decisions for his or her client.[121]

 

To handle such issues, a terminology known as “gaming the system” has been introduced. In order to provide services to the patients, a provider may at times present the information in such a way so as to make the case more appealing and thereby increase its chances of approval. This can work both ways for the practitioner. At one side it may mean that the provider will be able to provide the deserved care for the patient, on the other side tempering with the data may lead to serious litigation for the practitioner.[122]

 

 

 

 

CHAPTER 9:INCIDENTS ASSOCIATEDWITH DENIALS/RESTRICTION OF CARE

 

 

It is now well understood what purpose utilization review does in a health care system. This system mainly evaluates and decides what treatments and services are needed or will be needed, and the amount of these services required. But above all, this review at all times has to ensure the safety and the health of the patient. The functions of the utilization review can be stated in four terms, quality, appropriateness and level of care along with cost effectiveness of care. After assessing factors, the review places the patients in assisted living facilities, and continues to provide services through constant monitoring.

 

Denials in the utilization review process can take place when the department feels that the applicant has not fulfilled the necessary criteria and requirements of the healthcare act. It also has the right to revoke suspend, restrict or waiver a certificate or impose monetary penalties for violations.

 

The agent must therefore ensure that the application complies with the standards of the act and fulfills all its requirements prior to submission. Since the director has the right to investigate if these regulations are being followed, the review agent must be able to provide so, it the need arises.

 

The method of appealing falls under the 1996 Managed Care Reform Act, an appeal system for utilization review denial cases. This act supports applications on two formats. These are termed “appeals” and “grievances”. Appeals are made for cases that have been termed as medically unnecessary by the review. All other cases usually come under grievances and may include issues such as refusal to referrals to specialists, denials apart from the utilization review denials stating that such services are not part of the patient’s insurance contract. [123]

 

The appeal system as stated before is applied to cases that have been deemed unnecessary. This system at first meant that the patients can appeal only to their own physicians or health care practitioners selected by the plan. Since 1999, the patients have been given the right to have independent reviews conducted by persons who are independent from their health plan. Claims of denial on the basis that it is experimental or investigational can also be reviewed independently. [124]

 

Appeals can be categorized as expedited or standard appeals. Expedited appeals are for cases where the patient has started receiving the treatment and the health plan denies the continuation of the treatment. It can also be applied in cases where the hospital or its personnel feel that immediate appeal is necessary. Expedited appeals are decided within 2 working days of the application. Standard appeal is carried out within 45 days of the denial of the first application. These decisions are made within 60 days of receiving of application. [125]

 

If the case does not provide substantial proof, the case may be denied or be put in to other states mentioned above. A written statement usually ensues after the decision. However, the cases can be reconsidered if the applicant makes a written application within 30 days of the issuance of the statement. These applications are within the contextual framework of the different state laws, and the requests are sent to the departments for further review.[126]

 

Monetary penalties can be given if the director feels that the application violates the act. These can either be the submission of false information, or misdemeanor. Monetary penalties usually do not exceed the $5000 limit.[127]

 

If after much application and requests for grievance etc. are not answered positively, a person can then approach via the judicial review.

 

The documented form of the denial is issued to both the medical provider and the employee, within the ten of utilization review process. The document is marked notice of denial, and includes the statements reasoning why a certain application was denied, the information and the credentials of the reviewer, and a discussion of rights to reapply for reconsideration. [128]

 

If this occurs an application of reconsideration must be submitted within ten days of the issuance of statement of denial. To remove bias, these investigations are considered by an independent reviewer of the same qualification and not the previous one. This statement and decision is issued within the ten days of application of denial reconsideration application, and the document is named as the “final utilization review decision”.[129]

 

It is important that any information given at this point must be true and must be in relevance with the case application. If the information provided is authorized and is in accordance with the laws, consideration will be given. At such times, sometimes additional information is also required by the reviewer. [130]

 

Further review can take place if the application is again denied after the review process. In such incidences, the request is made to the reviewer who holds specialty in that particular field of interest of the patient. This physician is a certified specialist or a sub specialist, or a chiropractor, depending on the case. This “specialty reconsideration” is answered within 10 days of the application filed and is termed the “final utilization review decision”. [131]

 

The patient at this stage can appeal for reconsideration which is present in the medical bill audit. This request must be placed within 14 days of the final utilization review decision, and conduction will be carried out by a different reviewer with same level of qualifications as the previous reviewer. This decision is rendered final within 10 days of submission and is termed as “medical bill audit reconsideration decision.” Should the person feel the need for further evaluation, another request can be made within 30 days of the decision. [132]

 

For cases that the enforcement of a certain motion will lead to difficulties in the review to carry out the motion, a system of variance is applied. The variation however, must comply with the general purpose of the act and the intent of it. The director at this point will ensure that the variant is compliant with the public interest and health and is not detrimental to the safety of the employees.[133]

 

The system of variance is the same that is a written application is required to set the process in motion. This application will highlight the details and the basis of the matter in a comprehensive form. This application is then taken up for studying and if the case is legitimate, is approved. Otherwise the case is denied. Denials can be appealed against as well, but usually this means that a hearing date, time and place are given to discuss the case of denial.[134]

 

 

 

 

 

 

 

 

 

 

 

 

CHAPTER 10: PARITY BETWEEN MENTAL ILLNESS AND OTHER ILLNESS

 

Mental health care has received very less attention in the past as compared to other areas of health care delivery when considering the role of managed care and utilization review. The benefits given are very minimal, and therefore the question arises of how this issue will be brought to light and what efforts will be placed in providing the proper results in this area. This is the reason why the mental health care becomes an expensive burden on the patient as well as his or her family, and this results in large expenses should the need of an emergency treatment arise.[135]

 

It is here that the debate about parity issues arises. Parity reforms have been taking place in the mental health care sector for a very long time, and while these efforts have shown changes in the utilizations and the expenditures in this sector, no long term results have yet been complied. Current studies have revealed that based on the healthcare plans and insurance firms the level of parity for mental health differs. These differences have led to increased incidences of expenditures for the patients. A correlation between mental as well as physical health benefits have revealed that both of these increase or decrease synchronously. If mental health benefits are low, so would be the physical health benefits. The financial risk that this condition imposes requires that action be taken to reform parity laws. [136]

 

Parity laws have been in implementation since1956. This was a time in which each state handled the issue of mental health coverage on its own. The amount paid by the state at this time was about 85% and included among other things, housing, and food and employment opportunities. The expenditures of these services began to climb in the 70s and the 80s; some estimates stated it to be growing at twice the speed of the other health care facilities. This led to reduction of many of the facilities in mental health care. The reasons stated for these measures were that the system was being exploited by the patients who are taking longer therapies than required, and second that the responsibility of addressing the issues of chronic mental illnesses and addictions were of the state, and not of the private insurances. But the most biased concept arose that since mental illness does not really ever cure, therefore any efforts or resources placed will be futile and wasting.[137]

 

Parity laws were mainly designed to prevent any discriminatory actions in the health insurance companies between general and mental health care. These parity laws are available in many forms, and may “exclude substance abuse, apply to annual or lifetime benefit limits, limited to biologically based illness, not be applied to individuals with self insurance and include exemptions from smaller businesses.”[138]

 

Mental health is the optimum performance of the mental faculties of a person, which are evident through productive performances in everyday life, and improved and successful relationships with people around the person. A person with positive mental health is a positive contribution to the society in which he is living in. if any disorder takes place in this area; it is termed as mental illness. The health care system regarding the mental health care system is a complex array of public and private health systems, with general and special mental health provision setups. Not only these, it also includes “social services, housing, criminal justice, and educational agencies.” [139]

 

The problem with this system lies for people who cannot afford the system. The system although has evolved itself to include all areas of mental health care, it has made it all the more difficult to use for a consumer. To address the need, many changes have taken place, worthy of mentioning being the consumer and family movements. These organizations have played an active role in reducing and eliminating the stigma and the discriminatory attitude of the governments in shaping of mental health policies. Other areas of work include the promotion of the concept of self help, while recovering from mental illnesses. The organizations also focus on the diverse issues of special needs of the patients with regards to their condition, and “age, gender, cultural and racial identity of the patients.”[140]

 

Many other issues form the current picture of the mental health status. The current negative attitude among the public for mental illnesses has led to the patients shying away from treatment, including at times outright ignoring the need of mental health care. If this issue is too addressed, there is a growing need to remove stigma from the society, and reduce the misconceptions of the general public regarding mental health care and treatments. [141]

 

The lack of state of the art health services and limited health care providers compound the problem. Also needed is to reduce discrimination based on gender, race or ethnicity. Methods should be introduced that help in easy entry in to the system, while at the same time reducing the financial expenditure that is associated with the mental health care provision.[142]

 

The costs for mental health care provision for the year 1996 had been $99 billion, and has been continuously growing due to lack of proper policies and attention in the area. The mental health services have born the brunt of economical factors, including “market failures, adverse selection, moral hazard and public provision”[143]

 

The statistics show a very low number of people who are currently receiving mental health care in the United States. Only 10 percent of the children and adults receive any form of mental health care from health care specialists. Other places where these individuals may receive any form of mental care is from “clergy, social services and schools”.[144]

 

The parity legislation has led negligible cost increases but cannot be termed as successful solution to the mental health care problem. The Mental Health Parity Act states that those health plans covering “both the medical surgical as well as the mental health care aspects should not impose the annual lifetime dollars limits mental health benefits that are less than those applied to medical surgical benefits.”[145]

 

The problem does not address the services which are not providing mental health services at the moment. Therefore the applicability and implications automatically become limited. The act also does not address the issue of treatment of substance abuse treatments, and does not “preclude affected plans from using differential cost sharing, and day or visit limits. [146]

 

The current state laws have tried to improve the situation by mandating minimum coverage, the state laws mandate only certain benefits should the employer or the insurer chooses to offer mental health coverage. Many states however, have increased the parity laws by increasing the provisions of the federal law. This although, has helped in creating a better situation, there are still some areas and individuals who do not come under it. For example, the parity laws have provided coverage for patients demonstrating schizophrenia and bipolar disorder, while ignoring cases of post traumatic stress disorder, alcohol and drug addictions and autism.[147]

 

For a successful mental health care system, it is important that many policies be implemented. The areas that need the most attention are to introduce a scientific base for mental health care system, with researches focusing on providing the best health care to the patients. [148]

 

The mental health parity act is under much speculation. The decisions in this area are swinging precariously from either the law to go down, or full expansion of the law to include equivalence in deductibles, cost sharing and day/visit limits. The problem lies in the fact that very few people are actually acknowledging the inequities in the mental health care sector. These parity laws have led to more disparity between nominal and effective benefits, making the situation much worse. The effective benefits or the actual benefits the patient receives are much lower than the stated benefits in the policies. The only relief that has been provided in the condition is the intervention of the managed care, which has made the system and the treatments some what affordable to the patients. However, even managed care has not been able to address the issue ensuring access to health care benefits to these patients.[149]

 

So where does parity stand at this stage. Some say that the system has not adequately removed the equity and discrimination factors from the equation. But perhaps the main issue of concern lies in the costs that this parity act has led to. The recent NAMHC report to the congress has shown an increase of 1.4 percent in the total health benefits associated with full mental health parity.  This they claim is an overestimation as there is no accounting in the model of the impacts of these changes on the managed care systems. Roland Sturm made an interesting conclusion that by “removing common and arbitrary dollar and other limits and carefully managing mental health and substance abuse services would result in premium increases of only pennies per member per month.” Such observations have been consequently affirmed by other researchers as well.[150]

 

All in all the above observations have led to the deduction that incorporation of parities through the managed care will lead to benefits to patients having mental and addictive problems without significant increase in the costs. [151]

 

But full parity is only one of the steps in providing patients with mental health needs the best services comparable to other health care services. This approach, some critics say is an acknowledgment of the fact that parity is not an end solution to the problems of mental health seeking patients. An expansion of benefits has been the most significant result, but concurrent with this is the observation that unequal treatment opportunities have been produced when comparing psychiatric versus general medical conditions. A full parity has shown the removal of arbitrary and inequitable limits to the treatment.[152]

 

What leaves to be considered after the discussion is the consideration of those patients who do not have any health insurance at all. Full parity does not help in any way to such cases. But it is important that the factors other than parity and insurance issues be addressed that lead to non seeking behavior of treatment in the patients. These issues as discussed above merit the same attention as the others if a full improvement in the mental health care outcomes is desired.[153]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
CHAPTER 11: CONSEQUENCES AND EFFECTS OF VARIOUS UTILIZATION REVIEW DECISIONS ON MENTAL HEALTH OF PATIENT

The various processes of utilization review have been thoroughly discussed, examined and reviewed. The different procedures that are associated with it are integral to ensure health provision of the best level without overdue costs. Whatever decisions are made regarding the patient, whether he or she is provided, restricted or denied to care, all lead to different consequences, which in turn will influence the outcome of the whole utilization review process and managed care.

 

The main concern is that, not much has been done in the provision of care for patients who are mentally ill, and who do not have health insurance. This means that a large part of the population literally may go unnoticed and their medical needs unfulfilled. In this chapter, we look at some of the consequences, effects and outcomes of the various decisions of utilized review in caring for patient, with special emphasis on mental health issues.

 

One of the most prevalent mental illnesses in America is schizophrenia and bipolar disorder. The estimates have been made to be 4.5 million Americans. Concerns are that a major part of this population may not be receiving treatment in any form. The effects of non treatment are many, and can be a source of morbidity not to the patients themselves, but to their surroundings as well. The economical burdens and the financial costs are also large.[154]

 

Psychiatric illness patients are one of the most prevalent groups in people who are currently homeless. This accounts for one third of the 60,000 homeless people, most of them living in perhaps the worst situations. They are one of the most victims of the society, and with no food and shelter, live by on garbage cans.[155]

 

These patients are more prone to violence if left untreated. Recent surveys and report confirm that a majority of homicides carried out in the U.S each year are carried out by untreated schizophrenic or manic depressive patients. The two major demographic predictors of violent behavior are male sex and young age, and the two major clinical predictors of violence are the history of violence in the past and alcohol or drug abuse. This is followed by the clinical predictors of being mentally ill and not taking medication.[156]

 

One quarter of these are the murders of parents by their children, followed closely by murders carried out by siblings, by parents killing their children or spouses killing the other. The episodes are also more frequent until or unless the patients are hospitalized. On the other hand, the victimization of psychiatric patients is not only often ignored, but also is not followed through properly once it is established.[157]

 

These patients show the highest prevalence of suicide. 10 to 13% of the schizophrenia patients kill themselves, where as suicide rates in patients with bipolar disorder are even higher, up to 17% percent. This is a very large percentage when comparing it to the suicide rates among the general population, which accounts for only one percent.[158]

 

It is important to note that violent behavior and suicidal thoughts rarely come into patients’ minds that are undergoing therapy in any form, whether it is counseling, or through medications. Studies carried out to study the tendency of violence in these patients having treatment showed no significant differences from the general population statistics. However, patients’ not undertaking therapy or medication and being left untreated are more dangerous. Arrests, convictions, suicide, violence, agitation and psychoticism are most common features of such cases. There are many studies that have proven that without proper treatment, care and medication regime, the incidences of violence are very high.[159]

 

Although such individuals do show an increased tendency towards violence, the statistics reveal that out of all the violent episodes carried out in America; only 5% are carried out by such patients. Of these most prevalent were the violent attacks carried out by males than females. 10% of the male psychiatric patients are reported for violent behavior, with a lesser percentage of the female patients doing the same. This amounts to about 200,000- 250,000 numbers of patients displaying violent behavior.[160]

 

Perhaps one of the important factors complicating the issue is the fact that these patients are faced with discrimination due to the violent acts committed by a few of them. Many studies have shown and proved this tendency in the general population, to the point that even reading articles related to violent acts done by psychiatric patients lead to a negative response among the people. But reducing stigma without addressing the issue will be impossible and therefore what is required is to address and treat violent behaviors among the patients.[161]

 

This stigmatic approach leads to many destructive changes within an individual. The most common consequence of this stigmatism is the loss of a patient’s self esteem. This can occur in a variety of settings is named according to the situation the patient finds him or herself. Direct discrimination refers to situations where a person is refused a job, to structural discriminations, where the patient is given fewer resources for treatments. Lastly are the social psychological issues of stigma.[162]

 

A theory aptly identifies the social psychological stigma. The theory states that through the environmental exposures, social interactions, media and personal and peer relations, one comes to develop a particular concept about mental illnesses. This leads to individuals forming a rejecting attitude to persons who are mentally ill, claiming them to be cunning, stupid and incompetent. This issue never affects an individual until or unless he or she comes into this position in some point of his or her own life.[163]

 

This “fear of rejection”, can lead to a person who is utterly dejected, showing less social interactions or reducing them, “poor life satisfaction, unemployment and lack of income.” [164] This leads to further reduction in the perception of self esteem of the patient.

 

This issue gets more complicated when there is inadequate response from the society about the needs of these patients, and claiming them as a temporary situation that will resolve itself. The issue gets all the more complicated, for apart from the patient suffering from low esteem, he or she may now also feel self deprecation, or the feeling of inability to control one’s own life.[165]

 

The treatment of a case that has a psychiatric illness as well as substance abuse issues is more difficult, and more time consuming than treatments of both issues separately. The increased prevalence of substance abuse among persons with some mental disorder is a sign that needs to be checked by the health care provider during treatment, as substance abuse is one of the most important factors in producing violent changes of personality and mood.[166] The researches done on this subject have shown varying features in people using substances. In the U.S.A, for example, substance abuse showed concurrent increased criminal activities, mental illnesses and increased risk of committing or attempting suicide or hospitalizations. The issues that arise in these patients include the increased incidences of violent behavior, the risk of contracting HIV, with more effects on women as compared to men. The care systems, therefore, must provide integrated treatment systems, along with applications of “harm reduction, stage wise treatments, motivational interviewing, cognitive behavioral interventions, and 12 step help groups.”[167]

 

When discussing the role of managed care in treating cases with mental illness, it is seen that the managed care system is not equipped to handle such cases. The system lacks the longitudinal perspective that is critical in the health care delivery to the mental patients. Managed care in this regard also encourages health care providers to put minimum attention on these cases, leaving almost no medical provisions to the psychiatric patients.[168]

 

The questions are now forming if the method of providing limited sessions and medical and mental health  to a patient showing overt signs of self destruction is ethical or not. The methods of care delivery by the utilization system have led to many compromises in the health care system, and the moral aspects of it seem to be the most affected. For a competent management of a problem, a physician requires a certain autonomy placing the needs of the patient first, and addressing issues of consent and confidentiality etc. this autonomy is severely compromised when a physician or a psychiatrist is forced to “withhold information”.[169]

 

The trend has turned global since the 1980s, and the current health care systems are now under precarious conditions due to lack of funds, and the private insurances doing not provide adequate services. Managed care is one of the examples of such affected systems.[170]

 

The action however, soon proved that such a change in policy has only served to worsen the situation. Cases of mental illnesses can lead to incarceration, and the costs estimated were $15 billion per year in 1996.[171] The cost did not include the different procedural fees of the court, police, social services, and ambulance and emergency costs. The conclusions reached through this experience showed that although the initial costs of the mental health care management programs may be high, it was still very low when compared to individual cases of worsened mental conditions and incarcerations.[172]

 

The discrimination of the various health care programs has led to further worsening of the already fragile situation. The specific exclusion of patients’ payments in the state psychiatric hospitals when Medicaid was introduced was one of the first signs of discrimination shown to these patients. Not only did it foster deinstitutionalization, but also shifted the costs of the care to the states. Although Medicaid did provide health care for physical illnesses, it denied provision of care to any psychiatric needs of the patient. Even non psychiatric treatment in the psychiatric hospitals was not covered by the federal government. The issue got complicated for the patients as they were forced to opt for private insurance companies, the costs of which were not in their limits. Parity laws enacted only meant to serve those with less severe mental illnesses, leaving behind patients with sever illnesses with no door open. The interest of federal government to shift patients into Medicaid eligible services and to demote such patients from the hospitals has been carried out in order to deinstitutionalize the care system. [173]

 

These systems in which the patients are being transferred provide inferior services with limited or none rehabilitation programs, although the cost to the patient is still high. The public hospitals have shown greater admitting of those patients who presented with mild mental illnesses, turning away those who were in more severe and acute need of care in order to save costs. [174]

 

The result is that about 40 percent of the patients suffering from some severe form of illness are not receiving any medical care whatsoever. Many are now serving or are suffering in jails due to this neglect. And many are suffering from other issues such as discrimination, unemployment, violent behavior and victimization, homelessness, suicide and hunger.[175]

 

Other “costs” that are sometimes neglected in caring for the mentally ill patient include the consequently poorer conditions of transport and libraries, less usage of public parks, losses through suicides and the obvious effect on the immediate family of the patient.[176]

 

The role of the governments in the provision of mental health care is basic. It is these that must set policies to ensure such provision of care. Two areas come under consideration when discussing the issue. When considering the financial implications, it becomes the government’s policy to provide a system where health expenditures do not lead to “catastrophic financial risks”, the healthy and the well off should subsidize the sick and the poor.[177] These are not the only two aspects that need attention when discussing mental health issues. Policies for alcohol and drug abuse, and housing issues should also be addressed. Other policy issues should encompass the application of human rights accounting the need of vulnerable populations, community health services, availability of medications, and training of the health care workers. The application needs to be carried out both governmental and nongovernmental organizations, and ensuring the appreciation of cultural differences.[178]

 

Many suggestions have been put forward in providing care for mentally ill patients. By application of these ideas, much improvement is anticipated in providing improved care for these patients. The first and foremost need is the proper education of the care facilities about managing cases of mentally ill patients. The application of programs such as social skills trainings for people with mental retardation, and enhancing the vocational skills of schizophrenic patients are some of the programs that can be applied. [179]

 

The need to apply correct diagnostic principles and management techniques for cases with co morbid conditions is an important need for health care facilities. In managed care, the confirmed diagnosis is required for diagnosis before a complete assessment is carried out. Therefore the diagnosis made to apply for preauthorization may in fact have flaws in it. Also apart from psychiatrists, not many people know the methods of diagnosing psychiatric illnesses. Proper instigation and timing of the treatment will also help in providing and improving the condition of the patient. Along with these efforts to improve the basic skills of the patients such as language and communication skills, reading, writing, planning etc. help to improve the patient’s chances of improvement. [180]

 

Caring and supporting, as well as counseling of the patient’s family members if needed is an important part of the total rehabilitation process.  Similarly encouraging patient’s treatment through non medical care like introduction and taking part in social activities will help the patient in developing social skills and improve the general state of mind. Providing multidisciplinary care to patients can show positive results in cases which may not respond to a single treatment alone. By providing an effective system of care that is well coordinated and efficient, effective treatment can be carried out.[181]

 

Patients should be helped through different phases where chances of relapse can take place. These usually take place in times of changes, transitions, stress or certain life precipitating factors. By providing the patients a stable help force with a treatment plan that is personalized, the chances of readmission to the hospitals may be considerably reduced.[182]

 

The effect of denials in the provision of health care can be a very large set back for a patient. And can affect his perceptions about self. Such cases need to be appealed again by the care givers, so as to minimize effect on the self esteem of the patient. The appeal process may in fact approve of the previously denied service, and this chance can mean a whole lot to a person already burdened by mental sickness than any other patient. Such issues must include the broad social context of the patient’s environment and care must not be solely limited to provision of medical care. [183]

 

 

 

 

CHAPTER 12: LAW CASES ASSOCIATED WITH DENIAL OF CARE AND ITS OUTCOME.

There are many examples when upon denial of care from the utilization review boards, the applicant has filed a law suit on the utilization review or managed care or carried out some similar legal activity. The patients usually feel it is their right to be provided with care and any rejection or denial should be readdressed. Some of the cases related to utilization review, the managed care, and the various outcomes of the cases are described below.

One of the main concerns that are leading to law suits and investigations is the disturbing fact that HMOs, in their eagerness to reduce health care costs, are prioritizing it over the health of the patients. This can mean devastating results for the patients suffering from severe illnesses, physical or mental, since the costs of their treatments would be high.[184]

Doctors acting as gate keepers for the approval and provision of care are becoming a concern for the lawyers.  It is for this reason that the law agencies are now trying to limit the roles of HMOs as gate keepers, and in ensuring health care services to patients such as X-rays and referrals to the specialists etc. The results are now becoming apparent. Legislations such as 48 hour stays for birth giving mothers and child, reducing discriminations against the mentally ill, HMOs restricted to impose the gag rules, outlawing bonuses to HMOs withholding treatments etc. are now being enacted to protect the basic right of health care of the patients. The incentives for providing less has become a dangerous issue for patients with serious illnesses, as any efforts done on such cases would mean increased costs. [185]

David Ching is one of the many victims of the HMOs withholding of care in the managed care setup. His wife suffered from severe abdominal cramps, and for a checkup, David took her to one of the health maintenance organizations. Upon investigations, when no conclusion was reached, David interjected by stating that he wanted a specialist referral, but this became possible after three months of the initial investigations. By the time the permission was given, much time was lost for David’s wife, who was suffering from colon cancer, and died within 15 months of the discovery. [186]

David filed a lawsuit against the doctors stating that a specialist referral was denied as his (the specialist) pay would have come out of the doctors’ pockets. The law suit did not agree to David’s statement although it did grant compensation of $700,000, which of course did not erase the fact that his wife was by that time dead.[187]

The other case in review is Corcoran vs. United Healthcare Inc. Florence Corcoran was diagnosed with a high risk pregnancy for which she was advised by her obstetrician to spend the last month of pregnancy in a hospital. When she applied for it, the United Healthcare Inc. denied her request, giving her home nursing care. At home the fetus went into distress and died. This led to the “wrongful death action” by Mrs. Corcoran. This appeal however, did not go in favor of Mrs. Corcoran, and court stated that although the emotional distress that this issue caused was no doubt invaluable, however under ERISA, no compensation was present for such and the case ended not going in favor of Mrs. Corcoran. [188]

A slightly different case was the case of Dukes v. U.S. Health care. The widow of Mr. Duke stated that under the ERISA plan, Mr. Duke was given his health care. His case needed tests for blood sugar levels, which the health care denied. As a result, Mr. Duke died as a result of high blood sugar levels. The case, which was first brought forward in the state court, was shifted to federal court. At this point, the court stated the “claims were preempted by the conflict preemption clause.” This led to the Third Circuit Court Appeals, which decided the removal of these claims from the state court was improper. They stated that this case was in all measures a state law, under which the claimant can sue the Healthcare, and named the claims as a case of “quality of benefits”.[189]

Both these cases have pointed towards the pragmatic the more liberal interpretation of ERISA, which has not changed since it was implemented. An addition of three more cases came into the court’s view in the year 2000. These cases were of Lori Hedrich, Moran et al and Miller.[190]

Lori Hedrich was the patient of Dr. Pegram whom she visited when she started developing pain in her groin. She was advised an ultrasound as her doctor detected the presence of an inflamed mass in the abdomen.[191] But instead of ordering an ultrasound at a local unaffiliated hospital, Hedrich was told to go visit a hospital 50 miles away from her vicinity and that too after eight days of the first examination. This prolonged wait resulted in the rupture of her appendix leading to severe peritonitis. Hedrich brought suit in state court against both Dr. Pegram and the HMO. The case was removed to the federal court where Hedrich argued that the HMO and the doctor first placed their own interests instead of the patient. This motivation was present only because of the incentives the HMO provides to the doctors, leading to disastrous incidences like hers. This, she stated was in violation to the terms of ERISA. The claim was dismissed by the district court followed by the reverse of the Seven Circuit Court of Appeals. The decision was made that the treatment decision made by Dr. Pegram was not fiduciary acts under ERISA.  ERISA defines fiduciary as a “person acting in a capacity of a manager, administrator or financial advisor to the plan.” By this statement only eligibility statements and decisions are to be considered, which means if a plan decided covers the needed medical conditions. Dr. Pegram’s decision, according to the court was not fiduciary and is not violating the ERISA’s duty of providing “in the interest of the beneficiaries.”  With these statements, the court rejected the Hedrich claim.[192]

The Madrid vs. Gomez case is one of the examples of poor levels of care in the prison facilities and the mental health care delivery system. The Madrid plaintiffs stated that they were subjected to “unconstitutional conditions at a single institution rather than in the entire state prison system.” They stated that the inmates at the Pelican Bay State Prison face illegal and excessive violence by the officers, poor medical and mental health facilities. Along with these, the use of the special Security Housing Unit, “isolates inmates and constitutes unusual and cruel punishments.”[193]

Although the federal district court judge allowed the use of SHU, it made it clears that its use shall only continue “as long as inmated with serious medical problems likely to be aggravated by such isolation were no longer so confined. He addressed the issue of the poor medical and mental health care provision systems.[194]

The Carolina Care Plan Inc. vs. McKenzie, 2006 court case relates to the denial of cochlear implant of the patient. Carolyn L. McKenzie had joined the Carolina Care Plan through her employer. When she applied for the cochlear implant the plan refused to do so stating that it a computerized device to assist in communication and speech. Hearing aids in the Carolina Care Plan was listed in the section of appliances of “comfort and convenience”, and therefore, the rejection of the application. Carolyn’s physician argued that it was not an appliance of comfort or convenience, but rather was a prosthetic implant that coded sounds and replicated them electronically. When Carolyn filed an action in the U.S. district court, the court responded in favor of McKenzie, stating that a cochlear implant is not a comfort or convenience device, but rather one that removed disability, allowing the individual to function more productively in his or her environment. [195]

But let us not all blame the doctors. Although the managed care programs and the utilization review programs have affected the methods of healthcare delivery of most doctors. There are some who are resisting this structure, and stating that denying healthcare to patients is not what they intend to do. One of the prime case examples of such cases is of Dr. Linda Peeno, who by narrating her story, states the chilling mechanism within which the doctors are being forced to work with, without having to feel bad for the decisions they are making.[196] Dr. Linda Peeno was practicing as an illegal practitioner in California, as she had no license to practice their. Her employer, although aware of her status, was not concerned about the issue. And like other managed care and health insurance companies, the hospital where Dr. Peeno was working, wanted to reduce payments costs. Therefore, when a patient came who was in need of a heart transplant, Dr. Peeno, in the aim of avoiding payment, denied the need for it. The result was obvious, and the patient died. But Dr. Peeno became one of the “good” doctors of the company, as her denial saved it half a million dollars.[197]

This kind of promotion and applause for denying health care to needy patients in order to save money has become one of the crux of the utilization review, which is leading to indefinite and possibly irreversible damages to the healthcare system. This thought is now voiced on a stronger level. In 1997, the Journal of American Medical Association issued the statement “Call to Action” put forward by the Massachusetts physicians. The physicians stated the amount of pressure threats and bribes the healthcare staff had to bear in order to ensure delivery of care methods which are least costly. The doctors and the providers were forced to turn a blind eye to their “allegiance” to their patients, and to ignore patients who would not be “profitable” to the institute. Therefore, it is not a simple case of blaming the doctor, for the doctor him or herself is under considerable strain.[198]

Many cases have started to come to light that are demonstrating the financial relationships between the HMOs and the participating providers. One significant case related to this scenario is the Fox vs. Healthnet case. In this case, a woman had been denied bone marrow transplantation for breast cancer. The HMO had denied the bone marrow transplant by stating that this procedure is an investigational procedure. The plaintiff in reply stated that the definition the HMO used was very vague and precluded many routine procedures. Also by exposing the set of financial incentives that the HMO had for denying costly procedures, the plaintiff was able to prove the HMO guilty and settled for $77 million. [199]

All the cases that have been discussed raise questions to the accountability and the responsibility of the HMO in provision of care to the patients. Case in point is of Rae Ann Chase who gave birth to a retarded child in 1982. She sued her obstetrician by stating that she did not perform important tests during her pregnancy. The Independent Practice Association, which had contracted with Dr. Kauffman, was also sued for gyne/obs services. The court however, stated that IPA is not responsible for the actions of Dr. Kauffman, and is not liable for them. [200]

Judith Packevicz case is one of the grim illustrations of the effects utilization reviews can have on the health of the patients. This case also points out the dilemma doctors and specialists are faced with. Most of the specialist’s opinions are usually ignored when deciding the outcome of the application.[201]  Judith was diagnosed with a rare form of liver cancer, of which the best option was a liver transplant that would increased her chances of survival. Judith applied for the treatment but was denied. Thus began the struggle of the Packevicz family with the Mohawk Medical Valley Plan. Not only the financial and the legal litigation process a trying time for Judith and her family, it was reducing the mental and physical agony for the patient.[202] There was no problems with regards to the availability of treatment at a nearby medical facility, but the HMO refused stating that “it does not meet the medical community standard of care for this diagnosis.” without even conducting a physical examination.[203] The Packevicz family was forced to sue the company, upon which the company finally agreed to treat the patient. But by the time the approval was granted, Judith had become so weak that she did not sustain the operation and died during the surgery. For its defense, the MVP stated the case was not warranted, despite the fact that it was stated by her oncologist in a letter to MVP that she is in desperate need of liver transplant for the sake of her life. This letter was sent before the denial, but was of no use. [204]

Renee Berman’s case is also another case which demonstrates the worst case managements due to utilization reviews. Renee was diagnosed with liver cancer by five doctors, and was then examined by a sixth doctor, who was the head of the utilization review committee.[205] Despite the five recommendations of immediate liver transplant procedures, the head of the review committee denied the operation.  The treatment options were perfectly viable, that is they were not experimental or investigational, and was part of the services covered by the Health Net, of which she was the member. But the options were not within the skills of the Health Net, and this meant it Renee could pursue a treatment out of network. With this option in her hand Renee got her treatment, but at the expense of illogical denial basis, and a late treatment that could have cost her, her life. [206]

Health Net has literally become associated with denial cases, which are done so without any investigations or examinations. It is one of the worst examples of the utilization review process. Christine DeMeurers has been another victim of the review and HMO denial process. She was denied a life saving bone marrow transplant that needed to be given to her right away.[207] The procedure was recommended by the physicians and was part of her health coverage plan, but was approved after much struggle on Christine’s part. The treatment she received was delayed and was done by a university hospital with the expenses paid by the family’s own pocket. She did improve and her cancer did go into remission, but died a short time afterwards. Health Net was rebuked with $1 million by the arbitration panel, claiming this act as an abhorrent disregard of the patient’s life, the doctor patient relationship and the interference in the treatment plans of the patients.[208]

Health Net in this matter has not even spared its own employees, of which Janice Bosworth is witness. As a top employee for the Health Net Company, Janice was shocked to learn that her application for the treatment of cancer was denied. Her recovery warranted a bone marrow transplant along with extensive chemotherapy. The doctor at the hospital where Janice was receiving the treatment received a call stating that Health Net would not pay for the treatment, and the doctor was left saying he could do nothing in this case.[209] Upon further inquiry, Janice and her husband found out that the hospital was threatened with the cancellation of their contract of Health Net should they undertake the surgery. Janice and her husband threatened to sue Health Net, and with the intervention of Janice’s boss, she was finally able to receive her treatment free of cost, but the loss of her health and the possible effect of delayed treatment in her early death can never be compensated. [210]

What was perhaps the most disturbing finding was that the utilization reviewers, which mainly comprised of nurses or clerks, possessed the power to overrule the decisions of the doctors, when decisions regarding treatments were concerned.[211] A case warranting example is of a 6 month old boy, James Adams who was having a fever of 104. When the mother called the HMO hotline, the nurse on the other end told the parents to take the child to a hospital located 42 miles from their home, instead of directing them to a closer vicinity hospital. The baby at this time was already limp when the mother called, and by the time the parents were able to reach the hospital, he had gone into a cardiac arrest. Revival of the baby was successful, but by that time the circulation of the limbs of the boy had stopped, and in order to prevent the spread of gangrene, the doctors had to amputate his both arms and legs. The couple was insured with Kaiser Medical director.[212] After the hearing the jury awarded $45 million dollars to the couple. The audacity of the Kaiser Medical director, Richard Rodriquez, was incredible, for after the hearing he stated that the delay in the treatment did not lead to the amputations, and that issue was of quality, and this was only available at Kaiser’s.[213]

Many cases and stories are present that have shown the cruel neglect in part of health care delivery at the cost of people’s lives.  In 1993, Dawnelle Barris called for an ambulance as her 19 month daughter went into respiratory distress with the fever of 106 degrees. The daughter was taken to a local trauma centre, where the staff called Kaiser for treatment beyond basic breathing. Kaiser Representatives responded poorly.[214] On top of that, without any idea of the condition of the child, Kaiser refused any treatment beyond basic breathing and told the mother to bring the child in her car to a Kaiser hospital. Dawnelle refused seeing the deteriorating state of her daughter and begged the Kaiser representatives to send an ambulance for the baby. This they after confirmation that the baby now started having seizures, but still denied the application of antibiotics and initial blood work. Dawnelle was forced to carry her daughter in this state across the town to Kaiser Hospital, by that time which, Dawnelle had undergone cardiac arrest, and died. The autopsy confirmed that if the antibiotics were given at the right time, Dawnelle’s daughter would have survived. [215]

In relation to these issues, many conclusions have been drawn. The statistics have shown that up to 60% of the patients who are HMO patients have difficulty in getting treatment. The HMO patients above the age of 65 are 93% more liable to have declined health when compared with patients of the same age group getting fee for service health care. Around 50% of the Americans have verified the difficulty in getting health care from HMOs by hearing and experiencing such incidents. The HMO in its attempt to protect itself claims that the medical hospitals and the practitioners usually carry out excessive and unneeded tests in order to protect themselves from malpractice law suits.[216]

All these incidences are responsible for the increasing distrust of the public towards managed care. Studderd in his study came across some very interesting findings regarding utilization reviews and the frequencies of denials etc. Around 9% of the cases were usually denied in the utilization review processes. These denials were more seen in post service requests than among pre-service ones. The appeals that were filed included issues such as medical necessity of a certain service, “contractual limits on certain services, restriction of plan’s services for doctors outside the provider network,  and rejection of emergency care treatments by stating them as unnecessary.” Most common applications that were denied were for durable medical equipment, emergency care, laboratory or pathological services, speech therapy or chiropractic sessions. Estimates dictated that around 250,000 appeals were filed each year.[217]

To summarize, when emphasis becomes profit making and cost cutting in a health care system, the vulnerable patients are the first to suffer. These patients are the usual ones who are denied care, testing or referrals to specialists, hospital stays, treatments or any thing that is costly. The clinical services become the last place where money is invested and more is wasted on marketing and administrative jargon. Costs are also in these cases shifted to public care. This is because the private companies try to deny any way they can the service that is the right of the patient. The model of utilization review, by looking at the above examples, leads to one question in the end. Is the system worth it if it means the loss of health care standards and facilities, not to mention the number of morbidities and deaths associated with the denials of care? And what of the number of families that have been adversely affected by this system and may continue to do so if no measures are taken. These questions may change the face of health care delivery forever, and sadly, not for the better.[218]

 

 

 

 

CHAPTER 13: CONCLUSIONS AND RECOMMENDATIONS

 

Utilization management has shown an impressive reduction in the hospital expenditures and utilization, up to 12 percent. [219]Although from the economical angle, such a reduction is a reason for joy, in medical healthcare provision, this is only the least of concerns. For the effect that utilization review is having on the overall quality of health care provision is still unknown. Also, the limits it sets on the patients for reaching and getting care is disturbing. The recent research carried out by the Robert Wood Johnson Foundation has issued many findings in this regard. It concluded that although reducing the length of stay in the mentally ill patients may have been cost saving, it led to increased and early frequency of readmissions.  A reduction of hospital stays by six days increased the readmission chances to 30 percent. Also, the approval of mental health care provision has become more difficult with the passage of time. Only 1 percent of the total hospital admission cases were outright denied. However, restrictions were noticed in approval in cases of pediatric cases with time, which in the past were almost never denied. By reducing the average length of stay of patients with surgical problems, utilization management increased the chances of readmission by 2.7 times. [220]

 

Mental health care provision has become of concern in children as well. The number of children diagnosed with mental illness is increasing with only a few of these actually receiving any treatment. The timely treatment needs, along with the financial issues are one of the primary reasons for failure of receiving treatment. The costs of the treatments can be very high, even in the presence of the child’s insurance. Many of the conditions are not covered in the insurance plans and include “mental retardation, developmental disorders, and rational or abuse related problems.”[221] Recently the provision of treatment for such cases in children has been made mandatory in some of the states, a positive step in ensuring treatments to children. The inclusion can help in the affordability of the treatments, and may allow patients with multiple needs to gain access to services. [222]

 

Utilization review process is no doubt a need in the current American health care system, at least until the time a new improved system is introduced. The different aspects that govern the utilization review and the role of multiple key players have sadly shifted the original intention of providing quality care, to providing minimal care. Although supporters may contend that utilization review and managed care are one of best models of healthcare there is, they cannot deny the fact that it is starting to affect the level of commitment institutions have in provision of quality healthcare. Ignoring to do so is not only leading to general dissatisfaction among the public, but also the policy makers, who now see the disastrous effects managed care has in making doctors puppets in decision making for their patients.

 

By relieving a doctor from his role of providing excellent care to the patient through the utilization review, not only a doctor is ethically misusing his position, but is also forced to use false methods and techniques to give the patient the desired treatment he or she may deserve. The delayed procedures of denials and appeals only lead to worsening of the patient’s conditions, leading to more losses than initially expected.

 

Utilization review and managed care have been especially unkind to the mentally ill, who are almost always made scapegoats for the provision of physical health care. Despite the efforts that were placed to improve provision of mental health, managed care has led to worsening of many areas in mental health with increased costs due to emergency readmissions. Parity laws have been more ambitious on the papers, but actual application of these laws and derivation of full benefits is still a long task ahead. Unless radical reforms and are introduced in managed care regarding mental care, there is not much hope ,mental health care and its patients will benefit from managed care and utilization reviews.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

 

A Report of the Surgeon General. Executive Summary DEPARTMENT OF HEALTH AND HUMAN SERVICES U.S. Public Health Service

 

Accredition of Health Care Management Services. Site last accessed on December 20th, 2006 http://www.urac.org/resources/accreditation.aspx

 

AHCPR Research About Managed Care Organizations, Carolyn Clancey, 1996. Site last accessed on December 20th 2006. http://www.managedcaremuseum.com/archives/Artcl122.htm)

 

Robert A. Bailey, 1999. Care of Chronically Mentally Ill Patients in a Managed Care Environment. American Journal of Psychiatry,156: 1801-6.

 

Jill Rach Beisel, Jack Scott,  and Lisa Dixon. Co-Occurring Severe Mental Illness and Substance Use Disorders: A Review of Recent Research. Journal of Psychiatr Serv 50:1427-1434, November 1999

 

William E. Block, Applying Utilization Review Procedures in a Community Mental Health Centre. Journal of Hospital and Community Psychiatry.  Site accessed on December 20th, 2006. http://psychservices.psychiatryonline.org/cgi/reprint/26/6/358.pdf

 

Briefing Paper, 2003. Violent Behavior: One of the Consequences of Failing to Treat Severe Mental Illnesses. Site last accessed on December 25th, 2006. http://www.psychlaws.org/BriefingPapers/BP8.htm

 

Philip J. Boyle & Daniell Callahan. 1995.Managed Care in Mental Health: The Ethical Issues. Health Affairs,  Vol 14 No. 3

 

Martina Darragh and Pat McCarrick Managed Health Care: New Ethical Issues for All. Site last accessed on decenmber 20th, 2006 http://www.georgetown.edu/research/nrcbl/publications/scopenotes/sn31.pdf.

 

Division of Workers Compensation, the Utilization Review Standards, Title 8. California Code of Regulations, 2005. https://www.dir.ca.gov/dwc/DWCPropRegs/UR_2nd15dayProposedRegs.pdf.

 

DoH, 1993. Rules and Regulations for the Utilization Review of Health Care Services.

Robert A. Dorwart, 1990. Managed Mental Health Care.: Myths and Realities in the 1990s. Hospital and Community Psychiatry. Vol 41 No, 10 Pg. 1087-1091

 

Fact Sheet, CONSEQUENCES OF NON-TREATMENT. Treatment Advocacy Centre, Site last accessed on December 25th, 2006. http://www.psychlaws.org/generalResources/Fact1.htm

 

Fact Sheet. Medicaid Discrimination Against People With Severe Mental Illnesses. Treatment Advocacy Centre. Site last accessed on December 26th, 2006. http://www.psychlaws.org/GeneralResources/fact12.htm

 

Donna Marie Fick, Jennifer L. Waller,  John Ross Maclean, Richard Vanden Heuvel, J. Gary Tadlock, Marc Gottlieb, and Charles B. Cangialose. 2001. Potentially Inappropriate Medication Use in a Medicare Managed Care Population: Association with Higher Costs Utilization. Journal of Managed Care Pharmacy, 2001: 407-413

 

Kathryn E. Flynn, Maureen A. Smith, and Margaret K. Davis, From Physician to Consumer: The Effectiveness of Strategies to Manage Health Care Utilization NIHPA 2002Med Care Res Rev. 2002 December; 59(4): 455–481.

 

Jeffery L. Geller, William H. Fischer, Melissa McDermiet, and Julie Marie Brown,1998. The Effects of Public Managed Care on Patterns of Intensive Use of Inpatient Psychiatric Services. Journal of  Psychiatric services,49-327-332 http://www.psychservices.psychiatryonline.org/cgi/content/full/49/3/327)

 

Joan B. Gerbasi. 2003. Managed Care and ERISA: Synopsis and Case Law Review. Journal of American Academy of Psychiatry and the Law.31: 364-71.

 

Daniel P. Gitterman, Roland Sturm, and Richard M. Scheffler.2001, Toward Full Mental Health Parity and Beyond. Health Affairs, Vol 20 No. 4

 

Stephen A. Green and Sidney Blotch, 2001. Working in a Flawed Mental Health Care System: An Ethical Challenge. American Journal of Psychiatry158: 1378-1383

 

Health Insurance and Managed Care Appeals and Grievances for Patients Under the New York Managed Care Reform Act.  1999 www.healthcarechoices.com

Kevin D. Hennessey, Howard H. Goldman. Full Partiy: Steps Towards Treatment Equity for Mental and Addictive Disorders. Health Affairs Vol 20 no.4 2001.

 

Robert E. Hurley & Stephan A. Somers, 2003 Medicare and Managed Care: A Lasting R Relationship? Site last accessed on December 20th, 2006. http://www.psychservices.psychiatryonline.org/cgi/content/full/50/1/39

 

Title 8 Industrial Relations, Division 1. Department of Industrial Relations,

CHAPTER 4.5. Divisiuon of Workers’Compensation, Subchapter 1. Administrative Direction—Administrative Rules, Article 5.5.1 Utilization Review Standards, site last accessed on December 20th 2006  http://www.dir.state.ca.us/dwc/DWCPropRegs/UR_TextFinalRegulations.pdf.

 

Inside the Black Box of Managed Care Decisions: Understanding Patient Disputes Over Coverage Denials. Rand Corporation. Site last accessed on December 25th, 2006. www.rand.org

 

Managed Care Ethics in Medicine, Nancy S. Jecker, 2000, University of Washington, site last accessed on December 20th 2006.  www.universityofwashington.com

Alan Koike, Ruth Klap and Jurgun Unutzer, 2000. Utilization Management in a Large Managed Behavioral Health Organization, Journal of Psychiatric Services 51:621-626.

 

 

David Mechanic, 2002. Removing Barriers to Care Among Persons with Psychiatric Symptoms. Menal Health, 2002. Project HOPE.

 

David Korn, 2006, Academic Medicine and Managed Care: An Uncertain Future. http://www.amsa.org/programs/gpit/acadmed.cfm

 

Legislative Analyst’s Office, Department of Corrections (5240) Inmate Legal and Medical Issues, 1995. Site last accessed on December 25th, 2006. http://www.lao.ca.gov/analysis_1995/chd5240d.html

Bruce G. Link, Ph.D., Elmer L. Struening, Ph.D., Sheree Neese-Todd, M.A., Sara Asmussen, Ph.D. and Jo C. Phelan, Ph.D. Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People with Mental Illnesse Psychiatric Serv 52:1621-1626, December 2001
Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html

 

Managed Care, A Brief History,2003. Site last accesses on December 20th, 2006 http://www.healthteam.msu.edu/imc/modules/UMC2003/section1.htm

 

Managed Behavioral Health Care Firms and Institutional Theory: Is the Case Convincing,  Site last accessed on December 20th, 2006. http://www.institute-shot.com/managed_mental_health_care

Managed Care Organisations, Domenic Mantella, 2006 Site last accessed on December 20th, 2006 http://www.amcp.org/data/nav_content/1stPres.ppt.)

Robert Mechanic, Will Care Management Improve the Quality of US Health Care?, 2004 site last accessed on December 20th, 2006. http://council.brandeis.edu/pubs/Princeton%20XI/Rob%20Mechanic%20paper.pdf

 

Jack B. Miller,  Michael S. Rose,  Michael Milakovich,  Edward J. Rosasco, Jr. Application of TQM principles to the utilization management process – total quality management – Medical Quality Management. Physician Executive, 1992. Site last accessed on december 20th, 2006 http://www.findarticles.com/p/articles/mi_m0843/is_n3_v18/ai_12224742

 

PATIENTS’ BILL OF RIGHTS ACT OF 1998 H.R. 3605/S. 1890 Section-by-Section Analysis. Site last accessed on December 20th 2006.
http://www.house.gov/commerce_democrats/comdem/pbor/secbysec.htm

;

Pamela B. Peele, Judith R. Lave, and Kelly J. Kelleher, 2002.Exclusions and Limitations in Children’s Behavorial Health Care Coverage.  Journal of Psychiatric Services,  53:591-594

;

Linda Peeno, 2002. Presentation to the Romanov     Commission on the Future of Health Care of Canada.  Site last accessed on December 25th, 2006. http://www.healthcoalition.ca/peeno.pdf

;

Vallerie Propper and Ginger L. Pomiecko,  Parity for Mental Health: History and Consequences. Site last accessed on December 25th, 2006. http://www.case.edu/med/epidbio/mphp439/Parity_Mental_Health.htm

;

[1] Jennifer Rankin, 2004. Develoments  and Trends in Mental Health Policies. Institute for Public Policy Research https://www.ippr.org/members/download.asp?f=/ecomm/files/developments%20and%20trends%20in%20mental%20health%20policy.pdf;a=skip

;

Spencer Rich, 1996. Managed Care, Once an Elixir, Goes Under Legislative Knife. Managed Care Special Report. Site last accessed on December 25th, 2006 www.washingtonpost.com

;

Linda Rudolf, Joshua Linford and Kathy Dervin 2001. Utilization Review in California’s Worker’s Compensation System. A Preliminary Assessment .

;

Rules and Regulations for the Utilization Review of Health Care Services. Department of Heatlh 2003.  State of Rhode Island

;

David Satcher, 2000. Mental Health, A Report of the General Surgeon- Executive Summary. Professional Psychology: Research and Practice Vol. 31 no.1 5-13

;

Shafer D. 2006.Court Overturns Cochlear Implant Denial. American Speech Language Hearing Association. Site last accessed on December 25th, 2006. http://www.asha.org/about/publications/leader-online/archives/2006/061128c.htm

;

Martin F. Shapiro, 1997. Rethinking Utilization Review, the New England Journal of Medicine, volume 333: 1353-1354

;

Edward F. Shay, 2006.Manage Care Liability. Physicians News Digest. Site last accessed on December 25th, 2006. http://www.physiciansnews.com/law/1196shay.html

;

State Compensation Insurance Fund, Utilization Review Program, 2005   http://www.scif.com/pdf/clmURprogram.pdf

;

1992 Sunrise Review, Health Care Utilization Review http://www.dora.state.co.us/OPR/archive/92HealthCareUtilizReviewFirms.pdf.

;

Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf

;

On the Meaning of a Rational Health System: The American Health System, Past, Current and Future, Uwe E. Reinhardt, 2001.Site last accessed on December 20th, 2006  http://conferences.mc.duke.edu/privatesector/dpsc2001/da.htm

;

Utilization Review and Medical Bill Audit, KRS chapter 342. 803 KSR 25:190

;

World Health Organization, 2006. Mental Health Policy and Service Provision.

;

Samuel H. Zuvekas , Jessica S. Banthin, Thomas M. Selden Mental health parity: what are the gaps in coverage?  1998 The Journal of Mental Health Policy and Economics, Volume 1, Issue 3 , Pages 135 -146

;

SAMHSA Report: Improving services for individuals at risk of, or with, co-occurring substance-related and mental health disorders. June. 1996.

;

;

;

;

;

;

;

;

;

;

;

;

;

;

;

;

;

;

[1] WHO Mental Health Policy Project: Addressing Needs, Improving Services (MHPP) 2002
[2] WHO Mental Health Policy Project: Addressing Needs, Improving Services (MHPP) 2002
[3] WHO Mental Health Policy Project: Addressing Needs, Improving Services (MHPP) 2002
[4] Advocacy for Mental Health,  WHO, 2003
[5] Advocacy for Mental Health WHO, 2003.
[6] Advocacy for Mental Health WHO, 2003.
[7] A Report of the Surgeon General. Executive Summary DEPARTMENT OF HEALTH AND HUMAN SERVICES U.S. Public Health Service
[8] Jennifer Rankin, 2004. Develoments  and Trends in Mental Health Policies. Institute for Public Policy Research https://www.ippr.org/members/download.asp?f=/ecomm/files/developments%20and%20trends%20in%20mental%20health%20policy.pdf;a=skip.
[9] SAMHSA Report: Improving services for individuals at risk of, or with, co-occurring substance-related and mental health disorders. June. 1996.
[10] A Report of the Surgeon General. Executive Summary DEPARTMENT OF HEALTH AND HUMAN SERVICES U.S. Public Health Service
[11] A Report of the Surgeon General. Executive Summary DEPARTMENT OF HEALTH AND HUMAN SERVICES U.S. Public Health Service
[12] Robert A. Dorwart, 1990. Managed Mental Health Care.: Myths and Realities in the 1990s. Hospital and Community Psychiatry. Vol 41 No, 10 Pg. 1087-1091
[13] Robert A. Dorwart, 1990. Managed Mental Health Care.: Myths and Realities in the 1990s. Hospital and Community Psychiatry. Vol 41 No, 10 Pg. 1087-1091
[14] WHO, Advocacy for Mental Health. 2003
[15] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3
[16] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3
[17] WHO, Advocacy for Mental Health. 2003
[18] WHO, Advocacy for Mental Health, 2003.
[19] David Mechanic, 2002. Removing Barriers to Care Among Persons with Psychiatric Symptoms. Menal Health, 2002. Project HOPE.
[20] David Mechanic, 2002. Removing Barriers to Care Among Persons with Psychiatric Symptoms. Menal Health, 2002. Project HOPE.
[21] David Mechanic, 2002. Removing Barriers to Care Among Persons with Psychiatric Symptoms. Menal Health, 2002. Project HOPE.
[22] David Mechanic, 2002. Removing Barriers to Care Among Persons with Psychiatric Symptoms. Menal Health, 2002. Project HOPE.
[23] WHO, Advocacy for Mental Health, 2003
[24] WHO, Advocacy for Mental Health, 2003
[25] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.

;
[26] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.

;
[27] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.

;
[28] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.
[29] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.
[30] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.

;
[31] Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf
[32] Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf
[33] Managed Care, Nancy S. Jecker, 2000  www.universityofwashington.com
[34] Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf
[35] Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf

;
[36] Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf
[37] Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf

;
[38]Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf
[39] Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf
[40] Managed care organisations, Domenic Mantella, 2006 Site last accessed on December 20th, 2006 http://www.amcp.org/data/nav_content/1stPres.ppt.)
[41] Managed care organisations, Domenic Mantella, 2006 Site last accessed on December 20th, 2006 http://www.amcp.org/data/nav_content/1stPres.ppt.
[42] Tufts Managed Care Institute. A Brief History of Managed Care, 1998. Site last accessed on December 20th 2006. http://www.thci.org/downloads/BriefHist.pdf

;
[43] AHCPR Research About Managed Care Organizations, Carolyn Clancey, 1996. Site last accessed on December 20th 2006. http://www.managedcaremuseum.com/archives/Artcl122.htm)
[44] Managed care organisations, Domenic Mantella, 2006 Site last accessed on December 20th, 2006 http://www.amcp.org/data/nav_content/1stPres.ppt.
[45] Managed care organisations, Domenic Mantella, 2006 Site last accessed on December 20th, 2006 http://www.amcp.org/data/nav_content/1stPres.ppt.
[46] Managed Care Ethics in Medicine, Nancy S. Jecker, 2000, University of Washington, site last accessed on December 20th 2006.  www.universityofwashington.com
[47] Managed Care Ethics in Medicine, Nancy S. Jecker, 2000, University of Washington, site last accessed on December 20th 2006.  www.universityofwashington.com
[48] Managed Care Ethics in Medicine, Nancy S. Jecker, 2000, University of Washington, site last accessed on December 20th 2006.  www.universityofwashington.com
[49] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.
[50] Managed Care, A Brief History,2003. Site last accesses on December 20th, 2006 http://www.healthteam.msu.edu/imc/modules/UMC2003/section1.htm
[51]  Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.
[52] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.
[53] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.
[54] On the Meaning of a Rational Health System: The American Health System, Past, Current and Future, Uwe E. Reinhardt, 2001.Site last accessed on December 20th, 2006  http://conferences.mc.duke.edu/privatesector/dpsc2001/da.htm
[55] On the Meaning of a Rational Health System: The American Health System, Past, Current and Future, Uwe E. Reinhardt, 2001.Site last accessed on December 20th, 2006  http://conferences.mc.duke.edu/privatesector/dpsc2001/da.htm
[56] Managed Behavorial Health Care Firms and Institutional Theory: Is the Case Convincing,  Site last accessed on December 20th, 2006. http://www.institute-shot.com/managed_mental_health_care
[57] Managed Behavorial Health Care Firms and Institutional Theory: Is the Case Convincing,  Site last accessed on December 20th, 2006. http://www.institute-shot.com/managed_mental_health_care
[58] Robert E. Hurley ; Stephan A. Somers, 2003 Medicare and Managed Care: A Lasting R Relationship? Site last accessed on December 20th, 2006. http://www.psychservices.psychiatryonline.org/cgi/content/full/50/1/39
[59] Managed Behavorial Health Care Firms and Institutional Theory: Is the Case Convincing,  Site last accessed on December 20th, 2006. http://www.institute-shot.com/managed_mental_health_care
[60] Phillip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issue, 1995. Health Affairs Fall 1995.
[61] David Korn, 2006, Academic Medicine and Managed Care: An Uncertain Future. http://www.amsa.org/programs/gpit/acadmed.cfm
[62] Robert Mechanic, Will Care Management Improve the Quality of US Health Care?, 2004 site last accessed on December 20th, 2006. http://council.brandeis.edu/pubs/Princeton%20XI/Rob%20Mechanic%20paper.pdf
[63] Jeffery L. Geller, William H. Fischer, Melissa McDermiet, and Julie Marie Brown,1998. The Effects of Public Managed Care on Patterns of Intensive Use of Inpatient Psychiatric Services. Journal of  Psychiatric services,49-327-332 http://www.psychservices.psychiatryonline.org/cgi/content/full/49/3/327)
[64] Philip J. Boyle ; Danielle Callahan Managed Care in Mental Health: The Ethical Issues. Health Affairs, Volume 14, No. 3.

;
[65]
[66] Daniel P. Gitterman, Roland Sturm, and Richard M. Scheffler.2001, Toward Full Mental Health Parity and Beyond. Health Affairs, Vol 20 No. 4
[67] Daniel P. Gitterman, Roland Sturm, and Richard M. Scheffler.2001, Toward Full Mental Health Parity and Beyond. Health Affairs, Vol 20 No. 4
[68] State Compensation Insurance Fund, Utilization Review Program, 2005   http://www.scif.com/pdf/clmURprogram.pdf
[69] 1992 Sunrise Review, Health Care Utilization Review http://www.dora.state.co.us/OPR/archive/92HealthCareUtilizReviewFirms.pdf.)
[70] Donna Marie Fick, Jennifer L. Waller,  John Ross Maclean, Richard Vanden Heuvel, J. Gary Tadlock, Marc Gottlieb, and Charles B. Cangialose. 2001. Potentially Inappropriate Medication Use in a Medicare Managed Care Population: Association with Higher Costs Utilization. Journal of Managed Care Pharmacy, 2001: 407-413
[71] State Compensation Insurance Fund, Utilization Review Program, 2005 http://www.scif.com/pdf/clmURprogram.pdf
[72] State Compensation Insurance Fund, Utilization Review Program, 2005   http://www.scif.com/pdf/clmURprogram.pdf
[73] Martin F. Shapiro, 1997. Rethinking Utilization Review, the New England Journal of Medicine, volume 333: 1353-1354
[74] State compensation insurance fund, Utilization Review Program, 2005   http://www.scif.com/pdf/clmURprogram.pdf
[75] State compensation insurance fund, Utilization Review Program, 2005   http://www.scif.com/pdf/clmURprogram.pdf
[76] State compensation insurance fund, Utilization Review Program, 2005   http://www.scif.com/pdf/clmURprogram.pdf
[77] State compensation insurance fund, Utilization Review Program, 2005   http://www.scif.com/pdf/clmURprogram.pdf
[78] State Compensation Insurance Fund, Utilization Review Program, 2005   http://www.scif.com/pdf/clmURprogram.pdf
[79] Kathryn E. Flynn, Maureen A. Smith, and Margaret K. Davis, From Physician to Consumer: The Effectiveness of Strategies to Manage Health Care Utilization NIHPA 2002Med Care Res Rev. 2002 December; 59(4): 455–481.
[80] Division of Workers Compensation, the Utilization Review Standards, Title 8. California Code of Regulations, 2005. https://www.dir.ca.gov/dwc/DWCPropRegs/UR_2nd15dayProposedRegs.pdf.
[81] Kathryn E. Flynn, Maureen A. Smith, and Margaret K. Davis, From Physician to Consumer: The Effectiveness of Strategies to Manage Health Care Utilization NIHPA 2002Med Care Res Rev. 2002 December; 59(4): 455–481.
[82] Kathryn E. Flynn, Maureen A. Smith, and Margaret K. Davis, From Physician to Consumer: The Effectiveness of Strategies to Manage Health Care Utilization NIHPA 2002Med Care Res Rev. 2002 December; 59(4): 455–481.
[83] State Compensation Insurance Fund, Utilization Review Program, 2005   http://www.scif.com/pdf/clmURprogram.pdf )
[84] DoH, 1993. Rules and Regulations for the Utilization Review of Health Care Services.
[85] Alan Koike, Ruth Klap and Jurgun Unutzer, 2000. Utilization Management in a Large Managed Behavioral Health Organization, Journal of Psychiatric Services 51:621-626.

[86] Alan Koike, Ruth Klap and Jurgun Unutzer, 2000. Utilization Management in a Large Managed Behavioral Health Organization, Journal of Psychiatric Services 51:621-626.

[87] Jack B. Miller,  Michael S. Rose,  Michael Milakovich,  Edward J. Rosasco, Jr. Application of TQM principles to the utilization management process – total quality management – Medical Quality Management. Physician Executive, 1992. Site last accessed on december 20th, 2006 http://www.findarticles.com/p/articles/mi_m0843/is_n3_v18/ai_12224742
[88] Jack B. Miller,  Michael S. Rose,  Michael Milakovich,  Edward J. Rosasco, Jr. Application of TQM principles to the utilization management process – total quality management – Medical Quality Management. Physician Executive, 1992. site last accessed on december 20th 2006 http://www.findarticles.com/p/articles/mi_m0843/is_n3_v18/ai_12224742
[89] Jack B. Miller,  Michael S. Rose,  Michael Milakovich,  Edward J. Rosasco, Jr. Application of TQM principles to the utilization management process – total quality management – Medical Quality Management. Physician Executive, 1992. site last accessed on december 20th, 2006 http://www.findarticles.com/p/articles/mi_m0843/is_n3_v18/ai_12224742

;
[90] Title 8 Industrial Relations, Division 1. Department of Industrial Relations,

CHAPTER 4.5. Divisiuon of Workers’Compensation, Subchapter 1. Administrative Direction—Administrative Rules, Article 5.5.1 Utilization Review Standards, site last accessed on December 20th 2006    http://www.dir.state.ca.us/dwc/DWCPropRegs/UR_TextFinalRegulations.pdf.
[91] Title 8 Industrial Relations, Division 1. Department of Industrial Relations,

CHAPTER 4.5. Divisiuon of Workers’Compensation, Subchapter 1. Administrative Direction—Administrative Rules, Article 5.5.1 Utilization Review Standards, site last accessed on December 20th 2006    http://www.dir.state.ca.us/dwc/DWCPropRegs/UR_TextFinalRegulations.pdf.
[92] Title 8 Industrial Relations, Division 1. Department of Industrial Relations,

CHAPTER 4.5. Divisiuon of Workers’Compensation, Subchapter 1. Administrative Direction—Administrative Rules, Article 5.5.1 Utilization Review Standards, site last accessed on December 20th 2006    http://www.dir.state.ca.us/dwc/DWCPropRegs/UR_TextFinalRegulations.pdf.
[93] William E. Block, Applying Utilization Review Procedures in a Community Mental Health Centre. Journal of Hospital and Community Psychiatry.  Site accessed on December 20th, 2006. http://psychservices.psychiatryonline.org/cgi/reprint/26/6/358.pdf
[94] William E. Block, Applying Utilization Review Procedures in a Community Mental Health Centre. Journal of Hospital and Community Psychiatry.  Site accessed on December 20th, 2006. http://psychservices.psychiatryonline.org/cgi/reprint/26/6/358.pdf
[95] William E. Block, Applying Utilization Review Procedures in a Community Mental Health Centre. Journal of Hospital and Community Psychiatry.  Site accessed on December 20th, 2006. http://psychservices.psychiatryonline.org/cgi/reprint/26/6/358.pdf
[96] Accredition of Health Care Management Services. Site last accessed on December 20th, 2006 http://www.urac.org/resources/accreditation.aspx
[97] Accredition of Health Care Management Services. Site last accessed on December 20th, 2006 http://www.urac.org/resources/accreditation.aspx
[98] PATIENTS’ BILL OF RIGHTS ACT OF 1998 H.R. 3605/S. 1890 Section-by-Section Analysis. Site last accessed on December 20th 2006.
http://www.house.gov/commerce_democrats/comdem/pbor/secbysec.htm
[99] PATIENTS’ BILL OF RIGHTS ACT OF 1998 H.R. 3605/S. 1890 Section-by-Section Analysis. Site last accessed on December 20th 2006.
http://www.house.gov/commerce_democrats/comdem/pbor/secbysec.htm
[100] Linda Rudolf, Joshua Linford and Kathy Dervin 2001. Utilization Review in California’s Worker’s Compensation System. A Preliminary Assessment .
[101] Linda Rudolf, Joshua Linford and Kathy Dervin 2001. Utilization Review in California’s Worker’s Compensation System. A Preliminary Assessment
[102] Jack B. Miller,  Michael S. Rose,  Michael Milakovich,  Edward J. Rosasco, Jr. Application of TQM principles to the utilization management process – total quality management – Medical Quality Management. Physician Executive, 1992. Site last accessed on december 20th, 2006 http://www.findarticles.com/p/articles/mi_m0843/is_n3_v18/ai_12224742
[103] Jack B. Miller,  Michael S. Rose,  Michael Milakovich,  Edward J. Rosasco, Jr. Application of TQM principles to the utilization management process – total quality management – Medical Quality Management. Physician Executive, 1992. site last accessed on december 20th 2006 http://www.findarticles.com/p/articles/mi_m0843/is_n3_v18/ai_12224742
[104] Jack B. Miller,  Michael S. Rose,  Michael Milakovich,  Edward J. Rosasco, Jr. Application of TQM principles to the utilization management process – total quality management – Medical Quality Management. Physician Executive, 1992. site last accessed on december 20th, 2006 http://www.findarticles.com/p/articles/mi_m0843/is_n3_v18/ai_12224742

;
[105] Title 8 Industrial Relations, Division 1. Department of Industrial Relations,

CHAPTER 4.5. Divisiuon of Workers’Compensation, Subchapter 1. Administrative Direction—Administrative Rules, Article 5.5.1 Utilization Review Standards, site last accessed on December 20th 2006    http://www.dir.state.ca.us/dwc/DWCPropRegs/UR_TextFinalRegulations.pdf.
[106] Title 8 Industrial Relations, Division 1. Department of Industrial Relations,

CHAPTER 4.5. Divisiuon of Workers’Compensation, Subchapter 1. Administrative Direction—Administrative Rules, Article 5.5.1 Utilization Review Standards, site last accessed on December 20th 2006    http://www.dir.state.ca.us/dwc/DWCPropRegs/UR_TextFinalRegulations.pdf.
[107] Title 8 Industrial Relations, Division 1. Department of Industrial Relations,

CHAPTER 4.5. Divisiuon of Workers’Compensation, Subchapter 1. Administrative Direction—Administrative Rules, Article 5.5.1 Utilization Review Standards, site last accessed on December 20th 2006    http://www.dir.state.ca.us/dwc/DWCPropRegs/UR_TextFinalRegulations.pdf.
[108] William E. Block, Applying Utilization Review Procedures in a Community Mental Health Centre. Journal of Hospital and Community Psychiatry.  Site accessed on December 20th, 2006. http://psychservices.psychiatryonline.org/cgi/reprint/26/6/358.pdf
[109] William E. Block, Applying Utilization Review Procedures in a Community Mental Health Centre. Journal of Hospital and Community Psychiatry.  Site accessed on December 20th, 2006. http://psychservices.psychiatryonline.org/cgi/reprint/26/6/358.pdf
[110] William E. Block, Applying Utilization Review Procedures in a Community Mental Health Centre. Journal of Hospital and Community Psychiatry.  Site accessed on December 20th, 2006. http://psychservices.psychiatryonline.org/cgi/reprint/26/6/358.pdf
[111] Accredition of Health Care Management Services. Site last accessed on December 20th, 2006 http://www.urac.org/resources/accreditation.aspx
[112] Accredition of Health Care Management Services. Site last accessed on December 20th, 2006 http://www.urac.org/resources/accreditation.aspx
[113] PATIENTS’ BILL OF RIGHTS ACT OF 1998 H.R. 3605/S. 1890 Section-by-Section Analysis. Site last accessed on December 20th 2006.
http://www.house.gov/commerce_democrats/comdem/pbor/secbysec.htm
[114] PATIENTS’ BILL OF RIGHTS ACT OF 1998 H.R. 3605/S. 1890 Section-by-Section Analysis. Site last accessed on December 20th 2006.
http://www.house.gov/commerce_democrats/comdem/pbor/secbysec.htm
[115] Linda Rudolf, Joshua Linford and Kathy Dervin 2001. Utilization Review in California’s Worker’s Compensation System. A Preliminary Assessment .
[116] Linda Rudolf, Joshua Linford and Kathy Dervin 2001. Utilization Review in California’s Worker’s Compensation System. A Preliminary Assessment
[117] Robert Mechanic, 2004. Will Care Management Improve the Value of U.S. Health Care?
[118] Robert Mechanic, 2004. Will Care Management Improve the Value of U.S. Health Care?
[119] Robert Mechanic, 2004. Will Care Management Improve the Value of U.S. Health Care?
[120] Robert Mechanic, 2004. Will Care Management Improve the Value of U.S. Health Care?
[121] Martina Darragh and Pat McCarrick Managed Health Care: New Ethical Issues for All. Site last accessed on decenmber 20th, 2006 http://www.georgetown.edu/research/nrcbl/publications/scopenotes/sn31.pdf.
[122] Martina Darragh and Pat McCarrick Managed Health Care: New Ethical Issues for All. Site last accessed on decenmber 20th, 2006 http://www.georgetown.edu/research/nrcbl/publications/scopenotes/sn31.pdf
[123] Health Insurance and Managed Care Appeals and Grievances for Patients Under the New York Managed Care Reform Act.  1999 www.healthcarechoices.com
[124] Health Insurance and Managed Care Appeals and Grievances for Patients Under the New York Managed Care Reform Act.  1999 www.healthcarechoices.com
[125] Health Insurance and Managed Care Appeals and Grievances for Patients Under the New York Managed Care Reform Act.  1999 www.healthcarechoices.com
[126] Rules and Regulations for the Utilization Review of Health Care Services. Department of Heatlh 2003.  State of Rhode Island
[127] Rules and Regulations for the Utilization Review of Health Care Services. Department of Heatlh 2003.  State of Rhode Island
[128] Utilization Review and Medical Bill Audit, KRS chapter 342. 803 KSR 25:190
[129] Utilization Review and Medical Bill Audit, KRS chapter 342. 803 KSR 25:190
[130] Utilization Review and Medical Bill Audit, KRS chapter 342. 803 KSR 25:190
[131] Utilization Review and Medical Bill Audit, KRS chapter 342. 803 KSR 25:190
[132] Utilization Review and Medical Bill Audit, KRS chapter 342. 803 KSR 25:190
[133] Rules and Regulations for the Utilization Review of Health Care Services. Department of Heatlh 2003.  State of Rhode Island
[134] Rules and Regulations for the Utilization Review of Health Care Services. Department of Heatlh 2003.  State of Rhode Island
[135] Samuel H. Zuvekas *, Jessica S. Banthin, Thomas M. Selden Mental health parity: what are the gaps in coverage?  1998 The Journal of Mental Health Policy and Economics, Volume 1, Issue 3 , Pages 135 – 146
[136] Samuel H. Zuvekas *, Jessica S. Banthin, Thomas M. Selden Mental health parity: what are the gaps in coverage?  1998 The Journal of Mental Health Policy and Economics, Volume 1, Issue 3 , Pages 135 – 146

;
[137] Vallerie Propper and Ginger L. Pomiecko,  Parity for Mental Health: History and Consequences. Site last accessed on December 25th, 2006. http://www.case.edu/med/epidbio/mphp439/Parity_Mental_Health.htm
[138] Vallerie Propper and Ginger L. Pomiecko,  Parity for Mental Health: History and Consequences. Site last accessed on December 25th, 2006. http://www.case.edu/med/epidbio/mphp439/Parity_Mental_Health.htm
[139] David Satcher, 2000. Mental Health, A Report of the General Surgeon- Executive Summary. Professional Psychology: Research and Practice Vol. 31 no.1 5-13
[140] David Satcher, 2000. Mental Health, A Report of the General Surgeon- Executive Summary. Professional Psychology: Research and Practice Vol. 31 no.1 5-13
[141] David Satcher, 2000. Mental Health, A Report of the General Surgeon- Executive Summary. Professional Psychology: Research and Practice Vol. 31 no.1 5-13
[142] David Satcher, 2000. Mental Health, A Report of the General Surgeon- Executive Summary. Professional Psychology: Research and Practice Vol. 31 no.1 5-13
[143] David Satcher, 2000. Mental Health, A Report of the General Surgeon- Executive Summary. Professional Psychology: Research and Practice Vol. 31 no.1 5-13
[144] Kevin D. Hennessey, Howard H. Goldman. Full Partiy: Steps Towards Treatment Equity for Mental and Addictive Disorders. Health Affairs Vol 20 no.4 2001.
[145] David Satcher, 2000. Mental Health, A Report of the General Surgeon- Executive Summary. Professional Psychology: Research and Practice Vol. 31 no.1 5-13
[146] Kevin D. Hennessey, Howard H. Goldman. Full Partiy: Steps Towards Treatment Equity for Mental and Addictive Disorders. Health Affairs Vol 20 no.4 2001.
[147] Kevin D. Hennessey, Howard H. Goldman. Full Partiy: Steps Towards Treatment Equity for Mental and Addictive Disorders. Health Affairs Vol 20 no.4 2001.
[148] David Satcher, 2000. Mental Health, A Report of the General Surgeon- Executive Summary. Professional Psychology: Research and Practice Vol. 31 no.1 5-13
[149] Kevin D. Hennessey, Howard H. Goldman. Full Partiy: Steps Towards Treatment Equity for Mental and Addictive Disorders. Health Affairs Vol 20 no.4 2001.
[150] Kevin D. Hennessey, Howard H. Goldman. Full Partiy: Steps Towards Treatment Equity for Mental and Addictive Disorders. Health Affairs Vol 20 no.4 2001.
[151] Kevin D. Hennessey, Howard H. Goldman. Full Partiy: Steps Towards Treatment Equity for Mental and Addictive Disorders. Health Affairs Vol 20 no.4 2001.
[152] Kevin D. Hennessey, Howard H. Goldman. Full Partiy: Steps Towards Treatment Equity for Mental and Addictive Disorders. Health Affairs Vol 20 no.4 2001.
[153] Kevin D. Hennessey, Howard H. Goldman. Full Partiy: Steps Towards Treatment Equity for Mental and Addictive Disorders. Health Affairs Vol 20 no.4 2001.
[154] Fact Sheet, CONSEQUENCES OF NON-TREATMENT. Treatment Advocacy Centre, Site last accessed on December 25th, 2006. http://www.psychlaws.org/generalResources/Fact1.htm
[155] Fact Sheet, CONSEQUENCES OF NON-TREATMENT. Treatment Advocacy Centre, Site last accessed on December 25th, 2006. http://www.psychlaws.org/generalResources/Fact1.htm
[156] Fact Sheet, CONSEQUENCES OF NON-TREATMENT. Treatment Advocacy Centre, Site last accessed on December 25th, 2006. http://www.psychlaws.org/generalResources/Fact1.htm
[157] Fact Sheet, CONSEQUENCES OF NON-TREATMENT. Treatment Advocacy Centre, Site last accessed on December 25th, 2006. http://www.psychlaws.org/generalResources/Fact1.htm
[158] Fact Sheet, CONSEQUENCES OF NON-TREATMENT. Treatment Advocacy Centre, Site last accessed on December 25th, 2006. http://www.psychlaws.org/generalResources/Fact1.htm
[159] Briefing Paper, 2003. Violent Behavior: One of the Consequences of Failing to Treat Severe Mental Illnesses. Site last accessed on December 25th, 2006. http://www.psychlaws.org/BriefingPapers/BP8.htm
[160] Briefing Paper, 2003. Violent Behavior: One of the Consequences of Failing to Treat Severe Mental Illnesses. Site last accessed on December 25th, 2006. http://www.psychlaws.org/BriefingPapers/BP8.htm
[161] Briefing Paper, 2003. Violent Behavior: One of the Consequences of Failing to Treat Severe Mental Illnesses. Site last accessed on December 25th, 2006. http://www.psychlaws.org/BriefingPapers/BP8.htm
[162] Bruce G. Link, Ph.D., Elmer L. Struening, Ph.D., Sheree Neese-Todd, M.A., Sara Asmussen, Ph.D. and Jo C. Phelan, Ph.D. Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People with Mental Illnesse Psychiatric Serv 52:1621-1626, December 2001
[163] Bruce G. Link, Ph.D., Elmer L. Struening, Ph.D., Sheree Neese-Todd, M.A., Sara Asmussen, Ph.D. and Jo C. Phelan, Ph.D. Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People with Mental Illnesse Psychiatric Serv 52:1621-1626, December 2001
[164] Bruce G. Link, Ph.D., Elmer L. Struening, Ph.D., Sheree Neese-Todd, M.A., Sara Asmussen, Ph.D. and Jo C. Phelan, Ph.D. Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People with Mental Illnesse Psychiatric Serv 52:1621-1626, December 2001
[165] Bruce G. Link, Ph.D., Elmer L. Struening, Ph.D., Sheree Neese-Todd, M.A., Sara Asmussen, Ph.D. and Jo C. Phelan, Ph.D. Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People with Mental Illnesse Psychiatric Serv 52:1621-1626, December 2001

[166] Jill Rach Beisel, Jack Scott,  and Lisa Dixon. Co-Occurring Severe Mental Illness and Substance Use Disorders: A Review of Recent Research. Journal of Psychiatr Serv 50:1427-1434, November 1999
[167] Jill Rach Beisel, Jack Scott,  and Lisa Dixon. Co-Occurring Severe Mental Illness and Substance Use Disorders: A Review of Recent Research. Journal of Psychiatr Serv 50:1427-1434, November 1999
[168] Robert A. Bailey, 1999. Care of Chronically Mentally Ill Patients in a Managed Care Environment. American Journal of Psychiatry,156: 1801-6.
[169] Stephen A. Green and Sidney Blotch, 2001. Working in a Flawed Mental Health Care System: An Ethical Challenge. American Journal of Psychiatry158: 1378-1383
[170] Stephen A. Green and Sidney Blotch, 2001. Working in a Flawed Mental Health Care System: An Ethical Challenge. American Journal of Psychiatry158: 1378-1383
[171] Fact Sheet, CONSEQUENCES OF NON-TREATMENT. Treatment Advocacy Centre, Site last accessed on December 25th, 2006. http://www.psychlaws.org/generalResources/Fact1.htm
[172] Fact Sheet, CONSEQUENCES OF NON-TREATMENT. Treatment Advocacy Centre, Site last accessed on December 25th, 2006. http://www.psychlaws.org/generalResources/Fact1.htm
[173] Fact Sheet. Medicaid Discrimination Against People With Severe Mental Illnesses. Treatment Advocacy Centre. Site last accessed on December 26th, 2006. http://www.psychlaws.org/GeneralResources/fact12.htm
[174] Fact Sheet. Medicaid Discrimination Against People With Severe Mental Illnesses. Treatment Advocacy Centre. Site last accessed on December 26th, 2006. http://www.psychlaws.org/GeneralResources/fact12.htm

;
[175] Fact Sheet. Medicaid Discrimination Against People With Severe Mental Illnesses. Treatment Advocacy Centre. Site last accessed on December 26th, 2006. http://www.psychlaws.org/GeneralResources/fact12.htm
[176] Fact Sheet, CONSEQUENCES OF NON-TREATMENT. Treatment Advocacy Centre, Site last accessed on December 25th, 2006. http://www.psychlaws.org/generalResources/Fact1.htm
[177] World Health Organization, 2006. Mental Health Policy and Service Provision.
[178] World Health Organization, 2006. Mental Health Policy and Service Provision.
[179] Robert A. Bailey, 1999. Care of Chronically Mentally Ill Patients in a Managed Care Environment. American Journal of Psychiatry,156: 1801-6.
[180] Robert A. Bailey, 1999. Care of Chronically Mentally Ill Patients in a Managed Care Environment. American Journal of Psychiatry,156: 1801-6.
[181] Robert A. Bailey, 1999. Care of Chronically Mentally Ill Patients in a Managed Care Environment. American Journal of Psychiatry,156: 1801-6.
[182] Robert A. Bailey, 1999. Care of Chronically Mentally Ill Patients in a Managed Care Environment. American Journal of Psychiatry,156: 1801-6.
[183] Robert A. Bailey, 1999. Care of Chronically Mentally Ill Patients in a Managed Care Environment. American Journal of Psychiatry,156: 1801-6.
[184] Spencer Rich, 1996. Managed Care, Once an Elixir, Goes Under Legislative Knife. Managed Care Special Report. Site last accessed on December 25th, 2006 www.washingtonpost.com
[185] Spencer Rich, 1996. Managed Care, Once an Elixir, Goes Under Legislative Knife. Managed Care Special Report. Site last accessed on December 25th, 2006 www.washingtonpost.com
[186] Spencer Rich, 1996. Managed Care, Once an Elixir, Goes Under Legislative Knife. Managed Care Special Report. Site last accessed on December 25th, 2006 www.washingtonpost.com
[187] Spencer Rich, 1996. Managed Care, Once an Elixir, Goes Under Legislative Knife. Managed Care Special Report. Site last accessed on December 25th, 2006 www.washingtonpost.com
[188] Joan B. Gerbasi. 2003. Managed Care and ERISA: Synopsis and Case Law Review. Journal of American Academy of Psychiatry and the Law.31: 364-71.
[189] Joan B. Gerbasi. 2003. Managed Care and ERISA: Synopsis and Case Law Review. Journal of American Academy of Psychiatry and the Law.31: 364-71.
[190] Joan B. Gerbasi. 2003. Managed Care and ERISA: Synopsis and Case Law Review. Journal of American Academy of Psychiatry and the Law.31: 364-71.
[191] Joan B. Gerbasi. 2003. Managed Care and ERISA: Synopsis and Case Law Review. Journal of American Academy of Psychiatry and the Law.31: 364-71.
[192] Joan B. Gerbasi. 2003. Managed Care and ERISA: Synopsis and Case Law Review. Journal of American Academy of Psychiatry and the Law.31: 364-71.
[193] Legislative Analyst’s Office, Department of Corrections (5240) Inmate Legal and Medical Issues, 1995. Site last accessed on December 25th, 2006. http://www.lao.ca.gov/analysis_1995/chd5240d.html
[194] Legislative Analyst’s Office, Department of Corrections (5240) Inmate Legal and Medical Issues, 1995. Site last accessed on December 25th, 2006. http://www.lao.ca.gov/analysis_1995/chd5240d.html
[195] Shafer D. 2006.Court Overturns Cochlear Implant Denial. American Speech Language Hearing Association. Site last accessed on December 25th, 2006. http://www.asha.org/about/publications/leader-online/archives/2006/061128c.htm
[196] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[197] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[198] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html

;
[199]  Edward F. Shay, 2006.Manage Care Liability. Physicians News Digest. Site last accessed on December 25th, 2006. http://www.physiciansnews.com/law/1196shay.html
[200] Edward F. Shay, 2006.Manage Care Liability. Physicians News Digest. Site last accessed on December 25th, 2006. http://www.physiciansnews.com/law/1196shay.html
[201] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[202] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[203] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[204] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[205] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[206] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[207] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[208] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[209] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[210] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[211] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[212] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[213] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[214] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[215] Making a Killing. The End of Health Care. Site accessed on December 25th, 2006. http://www.makingakilling.org/chapter1.html
[216] Inside the Black Box of Managed Care Decisions: Understanding Patient Disputes Over Coverage Denials. Rand Corporation. Site last accessed on December 25th, 2006. www.rand.org
[217] Inside the Black Box of Managed Care Decisions: Understanding Patient Disputes Over Coverage Denials. Rand Corporation. Site last accessed on December 25th, 2006. www.rand.org
[218] Linda Peeno, 2002. Presentation to the Romanov              Commission on the Future of Health Care of Canada.  Site last accessed on December 25th, 2006. http://www.healthcoalition.ca/peeno.pdf
[219] Kelsely Menehan, 1999. Utilization Management Can Negatively Impact Health Care Quality and Access. The Robert Wood Johnson Foundation
[220] Kelsely Menehan, 1999. Utilization Management Can Negatively Impact Health Care Quality and Access. The Robert Wood Johnson Foundation
[221] Pamela B. Peele, Judith R. Lave, and Kelly J. Kelleher, 2002.Exclusions and Limitations in Children’s Behavorial Health Care Coverage.  Journal of Psychiatric Services,  53:591-594.
[222] Pamela B. Peele, Judith R. Lave, and Kelly J. Kelleher, 2002.Exclusions and Limitations in Children’s Behavorial Health Care Coverage.  Journal of Psychiatric Services,  53:591-594