Elizabeth L. Merrick, PhD, MSW¹, Constance M. Horgan, ScD², Deborah W. Garnick, PhD², and Dominic Hodgkin, PhD³. (1) Schneider Institute for Health Policy, Brandeis University, 415 South Street, Waltham, MA 02454, 781 736 3917, merrick@brandeis.edu, (2) Schneider Institute for Health Policy, Heller Graduate School, Brandeis University, 415 South Street, MS 035, Waltham, MA 02454, (3) Schneider Institute for Health Policy, The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MS 035, Waltham, MA 02454

The ways that health plans manage access to specialty behavioral health care have important implications for treatment by influencing both entry into and continuation in care. A 2003 survey on alcohol, drug abuse and mental health services collected data from over 400 health plans in 60 market areas, resulting in national estimates of how health plans structure treatment entry and continuation. In this paper, we report 2003 findings on gatekeeping and utilization management. We also compare selected findings to the 1999 round of the survey (response rate=92%) that only 7% of products required primary care physician referral but 73% required prior authorization to initiate outpatient care. We focus particularly on differences by managed care product type and by whether plans contract with managed behavioral health care organizations, as these variables were associated with different management approaches in 1999. These results have important implications for understanding initial access to (getting into) mental health and substance abuse services, and continued access (staying in). Variations in arrangements are important to employers in choosing health plans and to health plans in terms of deciding whether to contract out behavioral health services.

Learning Objectives: At the conclusion of the session, participants will be able to

• Describe the prevalence of several gate-keeping and utilization management approaches for substance sbuse treatment.
• Summarize changes in prevalence of gatkeeping and selected utilization management approaches since 1999.
• Describe how product type and contracting arrangements affect the use of gatekeeping and utilization management.

Keywords: Contracting, Managed Care

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.