Concerns About Managed Care Organizations

As managed care increasingly dominates both private and public sector mental health and substance abuse treatment services, serious concerns have been expressed by key stakeholders about whether managed care financing, if not properly administered, might in fact cause greater disparities than the fee-forservice system in meeting the critical needs of individuals with behavioral problems.

Their specific concerns include the following (Surles & Fox, 1998):

• Cost-cutting, which potentially threatens the quality of care

• Restructuring of services away from local, community-based approaches

• Relocation of services, which threatens accessibility

• Services provided to consumers by mental health professionals not familiar with the language, cultural values, and multiple needs of different groups

• Consumers’ lack of knowledge about how the managed care system works

• Language differences that interfere with communication and access to resources.

Professional guidelines, consumer report cards, and accrediting organizations are mechanisms that ensure provision of culturally competent health care services. Attention or inattention to cultural issues impacts both service delivery and service utilization that, in turn, affect not just quality, access, and utilization, but also costs. There would likely be an improvement in the utilization of services if policies, procedures, and guidelines addressed the unique cultural issues of consumers and providers (Lu, 1996).

Within the Federal Government, the Health Care Financing Administration is in the process of developing standards (1998) within its Quality Improvement System for Managed Care to include a statement that speaks to nondiscrimination for managed care enrollees based on sexual orientation.

The two largest accreditation bodies for managed care organizations are the National Committee for Quality Assurance and the Joint Commission on Accreditation of Healthcare Organizations. Neither organization has yet issued professional standards of practice related to the treatment of LGBT individuals, nor has either developed standards or quality measures regarding treatment of LGBT individuals that managed care organizations would be required to meet. Thus, for the consumer member of a managed care plan, whether public or private, there is no single requirement to ensure nondiscrimination based on sexual orientation.

Beyond one very specific project in Massachusetts (see the case example following), other “position” or “issue” statements can be found within several of the national associations that represent mental health practitioners. For example, the National Association of Social Workers (NASW) has developed a Policy Statement (1996) that articulates its position that a same-gender sexual orientation should be afforded the respect and rights given an other-gender orientation. NASW also supports curriculum policies in schools of social work that eliminate discrimination against lesbian, gay, and bisexual people and encourage the implementation of continuing education programs on practice and policy issues relevant to lesbian, gay, and bisexual people and cultures, as well as human sexuality.

The American Psychiatric Association (APA) has, since 1974, affirmed that certain sexual orientations are not a mental illnesses and has removed this diagnosis from all subsequent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The practice guidelines APA issued in 1995 prohibited specific discrimination against gay and lesbian clients (1995). In 1997, the American Psychological Association (in press) adopted a Resolution on Appropriate Therapeutic Responses to Sexual Orientation. In affirming a set of 13 principles, the American Psychological Association officially opposes portrayals of LGBT persons as mentally ill because of their sexual orientation and supports the dissemination of accurate information about sexual orientation and mental health and appropriate interventions in order to counteract bias that is based on ignorance or unfounded beliefs about sexual orientation.

A cursory review of key managed care stakeholders identified a significant number of professional associations, provider groups, private and public purchasers, accrediting groups, and others in a position to affect or advocate policy changes that specifically include sexual orientation or sexual identity as an important issue relative to clients and providers, including the following:

• Academy of Managed Care Pharmacy

• Addiction Prevention and Recovery Administration, Washington, DC

• American Medical Association Council on Scientific Affairs

• American Medical Student Association

• American Counseling Association

• Cambridge Preferred Provider Network of New York

• Council for Accreditation of Counseling and Related Educational Programs

• Employee Assistance Professional Association

• National Association of Alcoholism and Drug Abuse Counselors

• Patients’ Bill of Rights

• Pacificare of California

• Seattle-King County (WA) Department of Public Health

• Waukesha (WI) Memorial Hospital, Health System and Health Care, Inc.

In addition, the American Federation of State, County and Municipal Employees (AFSCME) continues to work to promote the rights of its lesbian and gay union members via the promotion of legislation that affects domestic partner benefits and to oppose discrimination based on HIV status. AFSCME has also issued a report (1994) resulting from its Presidential Advisory Commission that clearly states consumer rights issues within managed care. The Gay and Lesbian Medical Association’s (GLMA’s) recent policy (1998) “strongly urges HMOs [health maintenance organizations], PPOs [preferred provider organizations], and other managed care organizations to identify and provide referrals to providers with competence in LGBT health so that optimal patient care can be rendered to LGBT people.”