The Impact of Managed Care on Behavioral Health and LGBT Individuals

By the end of 1995, the behavioral health care benefits of 142 million individuals were provided under managed care contracts (IOM [Institute of Medicine], 1997), and the number continues to grow. Both private and public health care purchasers are largely contracting with managed behavioral health care organizations (MBHCOs) (IOM, 1996, 1997) to organize specialized mental health and substance abuse treatment for enrollees independently from overall health care. Purchasers, either private or public, contract with mental health and substance abuse treatment specialist organizations or preferred provider networks to organize specialized mental health and substance abuse treatment for enrollees independently from overall health care. Typically, MBHCOs assign specialist “gatekeepers” to assess and monitor clients’ need for access to and utilization of treatment within the network (ASAM [American Society of Addiction Medicine], 1999). Most individuals with private insurance have their behavioral health care needs met by some type of MBHCO (Schoenbaum, Zhang & Sturm, 1998). Managed care presents challenges for all behavioral health care providers and particularly so for those targeting LGBT individuals, because LGBT concerns are not well understood by—or even visible to—the leadership of managed care organizations.

The specific needs of LGBT individuals are not well understood by managed care organizations (MCOs). Moreover, few LGBT health care consumer organizations have overtly voiced the specific needs and concerns of this multicultural group. LGBT individuals, especially LGBT persons of color, thus remain hidden, neither accessing the health care system nor communicating honestly with health care providers—all of which has deleterious consequences for LGBT individuals needing treatment services. Clearly, providers of services to LGBT populations have much to gain by working together to make the case for improved services.

Fortunately, there are many groups attempting not only to make LGBT concerns visible to managed care administrators but also to deliver improved services. Designing and implementing successful treatment practices requires knowledge of the target populations. Thus, the critical need for administrators is to understand the existence of these subpopulations and to invite different LGBT populations to participate in the design of services and polices. Acknowledging this diversity and building appropriate mechanisms for consumer input will enhance the probability of successful treatment.

Why should a managed care and a clinical program consider a partnership between an LGBT program (LGBT-sensitive) and managed care? Managed care has recharged consumerism and awakened the health care delivery system to the requirement of providing access and quality services to an enrolled population in a culturally and linguistically appropriate manner (Kennedy, 1999). Some LGBT consumers or clients or patients (whatever terminology individuals wish to use in their self-identification) and LGBT health care providers are highlighting the needs of these constituencies to be taken care of in an appropriate and professional manner. However, in so doing, consumers risk not only antigay bias but also the stigma of identifying predisposing health conditions, such as HIV/AIDS, addictive diseases, and mental disorders that may alter benefits packages dramatically.

Another difficulty is that LGBT-identified persons can be seen as “high-cost-of-care” populations. Although data are not available to support or refute this supposition, several reasons can be suggested for the possibility of increased costs. First, managed care seeks to limit the number of patient visits and shorten the length of visits. As a result, a trustful provider/patient relationship may not develop and, therefore, disclosure of a person’s sexual orientation or sexual identity may not occur. The lack of this vital information may reduce the likelihood that appropriate care is provided in a timely fashion, thereby potentially raising its cost. Finally, some insurance companies have taken steps to reduce the probability of insuring an individual who may someday contract HIV (Li, 1996).

LGBT providers are also in a precarious position—self-disclosure may result in their exclusion from provider networks. The American Association of Physicians for Human Rights (now Gay and Lesbian Medical Association) (1994) found that 17 percent of self-identified gay and lesbian physicians had been fired, refused medical privileges, or denied employment because of their sexual orientation.

Despite the experiences of LGBT consumers and providers, incentives exist for MCOs to provide LGBT-sensitive services. It can be advantageous to a managed care company to attract business. Similarly, competent LGBT providers enhance the managed care company’s panel of providers and also satisfy the cultural and ethnic competency standards articulated in some States’ Behavioral Health Request for Proposal (RFP) (e.g., Iowa Substance Abuse RFP, pp. 30–17).