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Could a managed care contract be for you?

April 1, 2011
by Sue Bergeson
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Managed care contracts offer sustained funding-if your team can meet the requirements
Sue bergeson



Consumer and family-operated organizations, run by consumers or families that have benefited from behavioral health services, are valuable resources to others with mental health issues reach recovery and resiliency. They offer unique service approaches, including peer bridger programs, Wellness Recovery Action Plan (WRAP) training, drop-in centers, peer health coaching, family navigator support and parent and child education.

Unfortunately, as many of these organizations try to reach more people with their services, there has been an erosion of funding, notably from hard-hit state governments, but also from private donors. This has forced many such organizations to cut back or eliminate services.

For example: Cuts in Tennessee's state budget forced the Tennessee Mental Health Consumers' Association (TMHCA), a state-wide organization owned and operated by people with mental illness, to face the prospect of closing programs due to lack of funding.

But as THMCA searched for a solution to its funding challenges, it found one from an unexpected source: a managed care company. Managed care companies or organizations (MCOs) can offer consumer and family-run organizations the opportunity to become part of a behavioral health network and receive sustainable income. By contracting with an MCO, consumer and family organizations can continue to provide and expand access to their unique programs and services, without having to rely on donations or government funding.

Of course, a contract partnership also benefits the MCO, enabling it to offer new, community-based programs with proven results. Drawing on consumer and family organizations' roots in the community - where those with mental illness need access to resources and support - MCOs and the consumers we serve benefit as consumer and family organizations enhance wellness.

So, you're wondering: Could your consumer or family-operated organization benefit from working with a managed care company or organization? To help you find out, consider these best practices and issues, which are based on our experience at OptumHealth, a health and wellness company that works in the managed care environment.

What MCOs look for in consumer-run organizations

When considering a contract partnership with a consumer or family-run organization, MCOs look for programs that:

  • Provide high quality services that are compliant with state and federal regulatory requirements.

  • Ensure that their services can and do achieve positive, measurable results.

  • Support the principles of health care quality and affordability.

Of particular interest are peer-support programs that can educate consumers about their conditions, connect them to needed community and health resources, and provide new hope and alternatives to those who traditionally have been stuck in a revolving door of hospital admissions and relapses.

Note that MCOs continually evaluate whether they are offering a sufficient array of network services for their members. So, opportunities to contract with MCOs are constantly emerging.

Five considerations for consumer-run organizations

Joining a managed care network is a complex process and, therefore, is not for every organization. It is essential that organizations consider the pros and cons, to ensure that any MCO contract makes sense.

Here are a few key issues to consider:

1. Think critically about the organization's services and how they decrease hospitalization and/or increase well-being.

Organizations should be creative about the package of services that they offer. It is essential to show the MCO how your organization is being innovative, decreasing unnecessary hospitalizations, improving adherence to treatment, or increasing Healthcare Effectiveness Data and Information Set (HEDIS) scores. If your organization offers additional services, they should uniquely build on your organization's strengths.

For example, the New York Association of Psychiatric Rehabilitation Services (NYAPRS) and OptumHealth work together to offer peer bridger programs that link a consumer trained in promoting wellness and recovery to a consumer who has been recently and frequently hospitalized for behavioral health needs.

Working with the hospitalized consumer, the peer bridger helps create a “soft landing” back to the community; offers personalized support; and engages the consumer with Wellness Recovery Action Planning, crisis management resources, and hospital diversion supports.

A peer bridger may assist in helping an individual get home from the hospital; teach wellness tools such as journaling or exercising; or just be there to listen in the middle of the night. And, according to NYAPRS's analysis, they delivered outstanding results, yielding as much as a 71 percent reduction in hospital readmissions.

“The partnership between OptumHealth and NYAPRS is bringing new hope and support to consumers who have been trapped in an avoidable revolving door of relapse and re-hospitalization,” says Harvey Rosenthal, NYAPRS executive director. “It's a true win-win, helping and hiring consumers and helping states and our health partners to improve outcomes and reduce costs.”

2. Think about the impact of MCO contracting on your organization's culture, staffing, finances, stakeholders and services.

Consider these important “fit” questions before becoming a part of a managed care network.