Providers, health plans, and the management agents must document that patients get clinically better and that consumers are satisfied with their experiences. We are learning about consumer dissatisfaction because for the first time we are now systematically tracking consumer opinion. Within cost constraints, health plans, their management agents, and their providers must document performance. While mental health practitioners are now expected to integrate and coordinate their care and work in limited member networks emphasizing documented performance, they are also being paid with discounted fee structures. All of these paradigm changes have resulted in practitioner complaints.
Medical necessity is used for both access and service continuation.
Prior to managed care, private plans typically provided 30 days of inpatient hospitalization and 20 visits of psychotherapy a year. Insurance companies merely paid up to the limit. If a person had a serious mental illness they were then transferred to the public mental health system where state hospitals and community clinics with waiting lists dominated. Thus services were rationed within a two-class system. Managed behavioral healthcare uses the concept of medical necessity to access care.