Managed Care: Toward Open-Source Practices in Managed Behavioral Health

To the extent that health care purchasers differentiate and select managed behavioral health organizations that make available their information technologies, code, and key data, these organizations will benefit from open-source development. Although not central to employers' purchasing decisions, UBH is increasingly asked to share its technical methods with current and prospective purchasers of behavioral health services, including methods for evaluating clinicians, performing case-mix adjustment, warehousing its data, and using new data warehousing technologies to examine the cost and quality of treatment.

Each industry develops standards that facilitate the overall growth of the industry. Such standards are almost nonexistent in managed behavioral health, even in areas in which competitor-specific development is wasteful and nonsensical. For example, given the high degree of clinician overlap among provider networks, does it make sense for each managed behavioral health organization to develop its own provider profiling methods, practice guidelines, and performance standards? Why should different managed behavioral health organizations use different treatment improvement measures?

Even in our competitive private system, managed behavioral health organizations that are in direct competition with one another have significant incentives to participate openly in the development of information technology standards. Failure to participate may mean that an organization remains silent or lags behind important new developments in the industry. In the software industry, Internet standards have emerged largely because the stakeholders have the choice of either participating in development or being left behind. For example, the World Wide Web consortium is an organization devoted to providing open technology standards for the Internet. Its members include technology leaders such as Microsoft, Sony, and Sun Microsystems. One of the primary motivators for these companies is the opportunity to ensure that the open standards are in line with the companies' respective business models.

Technology development can be expensive—often too expensive to be shouldered by a single company. Distributing development costs across several companies can lower the cost for each company while producing a higher level of quality. For example, we know of no managed behavioral health organization that has the resources to address the methodologic challenges inherent in the single task of profiling clinicians, let alone to address policies and practices that affect many other aspects of the delivery of care. Meaningful progress in the development of appropriate methods for use by managed behavioral health organizations in the management of care will occur only if these organizations openly share their methods and data with each other and with health care purchasers, academic researchers, clinicians, consumers, and consumers' family members.

Peer review can dramatically improve the quality of any project. Adoption of an open peer-review process among managed behavioral health organizations would mean that every stakeholder in the delivery of behavioral health services could contribute to development by commenting, criticizing, making suggestions, or developing alternative approaches. Perhaps most important is the greater credibility that published performance measures would have. Academic standards of objectivity require that there be an opportunity to detect error and investigator misconduct. No such opportunity exists in the case of numbers released by managed behavioral health organizations to accrediting organizations and to others, despite obvious incentives and the potential for bias.

Communication is often considered a method for attaining an outcome, but it can also be considered an outcome of open-source development methods. As observed in the software industry, improvements in communication channels can result from collaborative efforts among managed behavioral health organizations. In addition to informal methods, such as Internet mailing lists, more structured approaches to communication can be developed. Many Internet standards have been developed through a request-for-comments process administered by the Internet Society (3). A request-for-comments document—for example, a technical report—results from the discussion process and can then be publicly referenced. Managed behavioral health organizations could use the same method, which would allow clinicians, consumers, and academic researchers to participate in the development of the system's information technology standards, including privacy and confidentiality standards.

Open-source development is not a panacea. Even projects that would benefit from open-source development involve risks. Early visionaries of the open-source software movement recognized that each project must have its own set of rules for development (4). For example, with some projects a single individual has complete control over the final choices; usually this individual is the person who initiated the project. With other projects, an elected committee or core team makes the final decisions. Some projects use a hybrid of these two approaches. We suggest that to control risk, managed behavioral health organizations should adopt a similar approach in which each open-source project develops a core team of individuals who establish a set of project rules or guidelines. These guidelines can be strict or loose, as long as they adhere to an open-source approach.

Licensing is another method that can be used to control risk. In the software industry, the participants in each project choose from among several software licenses. Some licenses are very specific about the current and future uses of the software—for example, the GNU General Public License holds that current and future extensions to the software must always include the source code. Other licenses are less restrictive—for example, the Berkeley Software Distribution License holds that current and future extensions to the software do not have to include the source code. The choice of license is open to the author of the code or the project team. Managed behavioral health organizations can adopt a similar approach. Each organization or project team could create its own license for a collaborative project, or the project itself could have a license.