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Evaluation of agreements between managed care organizations and providers of community-based mental illness and addiction disorder treatments.
Am J Manag Care. 2002 Feb; 8(2):135-47.AJ

Abstract

OBJECTIVE

To analyze the scope, content, and nature of contracts between managed care organizations (MCOs) and community-based mental illness and addiction disorder treatment and prevention service providers, focusing on implications for managed care policy.

STUDY DESIGN

Qualitative and quantitative document content analysis.

METHODS

We reviewed and coded 107 provider contracts from 17 states. Data were aggregated on MCO and provider demographics, scope of services, contractual obligations, and financial reimbursement mechanisms. Results were compared with those from a similar study conducted in 1996 with a sample of 50 contracts to identify changes over time.

RESULTS

The MCOs purchased relatively few services from providers, omitting many services integral to the proper management of mental illness and addiction disorders. Service duties were often ambiguously described, leading to potentially significant and unanticipated financial risk for providers. The MCOs exert strong control over treatment decision making. Capitation and other risk-based payment arrangements are increasingly common, although most continue to use fee-for-service reimbursement methods. Contracts are structured to remove provider bargaining power; they allow MCOs to unilaterally amend all provisions on notice and without negotiation and permit termination "at will."

CONCLUSIONS

Managed care contracts favor the needs of the managed care industry and are constructed to (1) shift significant amounts of financial risk onto providers and (2) manage and restrain providers' choices over the use of benefits through close oversight, financial controls, and incentives. Because a signed contract is a precondition to access to patients and insurance revenues, health professionals must sign them and indicate a general inability to negotiate their terms.

Authors+Show Affiliations

Center for Health Services Research and Policy, School of Public Health and Health Services, The George Washington University, Washington, DC 20006, USA.No affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Evaluation Study
Journal Article
Research Support, U.S. Gov't, Non-P.H.S.

Language

eng

PubMed ID

11853202

Citation

Rosenbaum, Sara, et al. "Evaluation of Agreements Between Managed Care Organizations and Providers of Community-based Mental Illness and Addiction Disorder Treatments." The American Journal of Managed Care, vol. 8, no. 2, 2002, pp. 135-47.
Rosenbaum S, Mauery DR, Teitelbaum J, et al. Evaluation of agreements between managed care organizations and providers of community-based mental illness and addiction disorder treatments. Am J Manag Care. 2002;8(2):135-47.
Rosenbaum, S., Mauery, D. R., Teitelbaum, J., & Vandivort-Warren, R. (2002). Evaluation of agreements between managed care organizations and providers of community-based mental illness and addiction disorder treatments. The American Journal of Managed Care, 8(2), 135-47.
Rosenbaum S, et al. Evaluation of Agreements Between Managed Care Organizations and Providers of Community-based Mental Illness and Addiction Disorder Treatments. Am J Manag Care. 2002;8(2):135-47. PubMed PMID: 11853202.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Evaluation of agreements between managed care organizations and providers of community-based mental illness and addiction disorder treatments. AU - Rosenbaum,Sara, AU - Mauery,D Richard, AU - Teitelbaum,Joel, AU - Vandivort-Warren,Rita, PY - 2002/2/21/pubmed PY - 2002/3/15/medline PY - 2002/2/21/entrez SP - 135 EP - 47 JF - The American journal of managed care JO - Am J Manag Care VL - 8 IS - 2 N2 - OBJECTIVE: To analyze the scope, content, and nature of contracts between managed care organizations (MCOs) and community-based mental illness and addiction disorder treatment and prevention service providers, focusing on implications for managed care policy. STUDY DESIGN: Qualitative and quantitative document content analysis. METHODS: We reviewed and coded 107 provider contracts from 17 states. Data were aggregated on MCO and provider demographics, scope of services, contractual obligations, and financial reimbursement mechanisms. Results were compared with those from a similar study conducted in 1996 with a sample of 50 contracts to identify changes over time. RESULTS: The MCOs purchased relatively few services from providers, omitting many services integral to the proper management of mental illness and addiction disorders. Service duties were often ambiguously described, leading to potentially significant and unanticipated financial risk for providers. The MCOs exert strong control over treatment decision making. Capitation and other risk-based payment arrangements are increasingly common, although most continue to use fee-for-service reimbursement methods. Contracts are structured to remove provider bargaining power; they allow MCOs to unilaterally amend all provisions on notice and without negotiation and permit termination "at will." CONCLUSIONS: Managed care contracts favor the needs of the managed care industry and are constructed to (1) shift significant amounts of financial risk onto providers and (2) manage and restrain providers' choices over the use of benefits through close oversight, financial controls, and incentives. Because a signed contract is a precondition to access to patients and insurance revenues, health professionals must sign them and indicate a general inability to negotiate their terms. SN - 1088-0224 UR - https://www.unboundmedicine.com/medline/citation/11853202/Evaluation_of_agreements_between_managed_care_organizations_and_providers_of_community_based_mental_illness_and_addiction_disorder_treatments_ L2 - https://www.ajmc.com/pubMed.php?pii=340 DB - PRIME DP - Unbound Medicine ER -