Best Practices: Transition of Enrollees From a Managed Care Organization to an Academic Managed Behavioral Health Carve-Out

In early 2000, AvMed Health Plan, the largest nonprofit MCO in Florida, awarded a full-risk capitation contract to University of Miami Behavioral Health to manage its South Florida mental health and substance abuse benefits for 186,634 commercial and Medicare covered lives. AvMed's statewide enrollment was 319,109 lives—covered by commercial insurance, point-of-service plans, Medicare, and Medicaid—of whom 58.5 percent were in South Florida (7).

University of Miami Behavioral Health is a division of the department of psychiatry and behavioral sciences of the University of Miami School of Medicine. It was established in 1993 as the managed behavioral health care carve-out for the faculty and staff of the University of Miami and their dependents (16,000 lives). Initially, the provider network comprised university faculty and community clinicians known to the university community. When planning began for the assumption of AvMed enrollees, the initial enrollee population had expanded to 40,000, and the provider network had increased to 100 licensed professionals. The ultimate expansion of services would increase enrollment by a factor of almost 5.

AvMed (the MCO) and University of Miami Behavioral Health (the MBHO) hoped to realize specific strategic advantages from the union. The MCO hoped to gain a high-quality delegate for behavioral health services and the prestige and recognition of the University of Miami in South Florida. Its primary concern was that the care of its enrollees not be disrupted. A measure of enrollee satisfaction would be the absence of telephone calls and complaints to AvMed's member services department during the 90-day transition of active enrollees. The academic MBHO was taking a calculated risk, because an expansion of five times its enrollee population would leave the organization vulnerable if full-risk capitation were not sufficient to cover utilization expenses. In addition, there would be a cultural shift from a small organization with a generous benefit plan and a provider network composed disproportionately of academic psychiatrists to a community-based network.

Implementation planning began on March 1, 2000, and the transition began on July 1, 2000.

The challenge facing both health care organizations was to plan the logistics of transferring ongoing treatment by identifying MCO enrollees who were in treatment, notifying their providers, and preparing both enrollees and providers for the change in behavioral health coverage. The MCO gave the MBHO an electronic list that was used to match active enrollees to providers inside and outside the MBHO network. The MBHO's network was expanded to include 95 percent of the MCO's providers in the case of geographic overlap between the two networks.

Thus MCO enrollees who were in active behavioral health treatment fell into two groups: those who were being treated by one of 75 providers who were already in the MBHO network, and those who were being treated by an MCO provider who was not in the MBHO network. The first group would make a smooth transition: providers were mailed a list of affected patients and were informed that after a given date they should request authorizations for continued care from the MBHO instead of from the MCO. Any benefit limits were transferred to the MBHO. For the second group, an innovative approach was required so that ongoing treatment would not be disrupted.

Multiple satisfaction-related outcomes were clearly defined by both the MCO and the MBHO at the outset of the planning process. The goal for each of these constituencies was to complete the organizational transfer with minimal disruption to ongoing treatment.

It has been suggested that disruption to care due to recent withdrawals of Medicaid managed care plans can be mitigated by overlap in local plans' provider networks and transition policies that affect enrollment (8). The experience we describe suggests that the same is true in behavioral health care. The relatively smooth transition of active enrollees should become the benchmark for all managed behavioral health care organizations.

Although spontaneous complaints from all stakeholders—patients, clinicians, employee assistance programs, health maintenance organizations, and so on—are an appropriate outcome measure for plan transitions, it is worth considering a more active approach to solicit such feedback. We hope that the extremely low rate of spontaneous complaints we received reflects our efforts toward a smooth transition. However, it is possible that if we had solicited complaints we would have received more of them. In the spirit of determining best practices, we recomend that future efforts in this area involve contacting and informing all stakeholders—ensuring anonymity when possible—and following up with anonymous satisfaction surveys.

Network integration and preemptive enrollee notification is contingent on the MCO's sharing the claims files of active enrollees with the MBHO. Unfortunately, such cooperation is unlikely without legislative intervention, because the outgoing MBHO has little or no incentive to assist the MBHO in the absence of an ongoing business relationship. At a minimum, there should be mandated contractual language and perhaps state statutes that require MCOs and MBHOs to provide active client data to new MBHOs at least 60 days before transition.

The authors are affiliated with University of Miami Behavioral Health. Dr. Brickman, Dr. LoPiccolo, and Dr. Eisdorfer are also with the department of psychiatry and behavioral sciences of the Miami School of Medicine. Send correspondence to Dr. Brickman at the Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine (M861), P.O. Box 016960, Miami, Florida 33101 (e-mail, [email protected]). William M. Glazer, M.D., is editor of this column.