Applying a Conflict Resolution Framework to Disputes in Managed Care

Conflict is variously defined as a direct disagreement of ideas or interests, a battle or struggle, antagonism or opposition, and incompatibility and interference. Sadly, such terms frequently apply to the delivery of mental health services in the 1990s, as health and mental health providers in a variety of settings come to terms with the ascendancy of managed care and its impact on their practice and clientele. Managed care typically refers to a range of strategies for ensuring that services are carefully structured and scrutinized to assure both fiscal responsibility and acceptable quality of care. Managed care is now the primary model under which health and mental health services are delivered in the for-profit, nonprofit, and public sectors. Although conflict is not inevitable in managed systems, some professional groups, client populations, areas of the country, and sectors of service may experience more difficulty adapting to the changes managed care brings than others. Disputes can occur when members of a treatment team differ about the services needed for a patient approaching discharge from a hospital or residential facility. Disputes can occur between a provider and a utilization reviewer, who disagree about whether certain services are "medically necessary" or covered by a client's benefit plan. And they can occur between a worker and a supervisor, when the worker objects to precise performance standards and the supervisor views them as essential for accountability and funding. As the climate for the provision of health and mental health services becomes increasingly competitive, as budgets become tighter and expectations increase, the stakes in such disputes go beyond the substance of the disputes themselves. In what Coser (1956) referred to as the "nonrealistic" elements of conflict, the dispute becomes exacerbated by the emotions and tensions accompanying the substantive or "realistic" concerns. Indeed, many articles document the apprehensions and experiences of clinicians and clients adjusting to practice under managed care mechanisms (Brown, 1994; Davidson & Davidson, 1996; Karon, 1995; Paulson, 1996), but few offer direction about how those difficulties can be addressed successfully. Conflict resolution models offer a viable and tested framework that can be applied easily and effectively in a range of disputes, providing practitioners with ethically and clinically sound resolutions to managed care difficulties. This article describes the principles and strategies of one form of conflict resolution - negotiation - and demonstrates its application for a range of managed care disputes. The article concludes with an analysis of the complexities in using such a model, particularly when there are pronounced power differentials among the participants. Understanding Conflict Sources of Conflict Whatever the conflict, it likely stems from one or a combination of the following origins (Moore, 1986): inconsistencies in data; relationship issues; value conflicts; structural problems, such as unequal power or resources or geographic or physical barriers; and conflicts about interests. The genesis of the conflict is important as each source leads to different considerations for resolution. For example, a mental health provider and an insurance representative might be in conflict over the provider's rating. The provider is concerned that a low rating will mean that referrals from that source will cease and is anxious to fight the rating and the rater. The nature of the dispute may stem from each party having inadequate data (for example, the therapist's average length of treatment is an noncompetitive 15 sessions, yet the payer representative may not know that a small number of cases has skewed the figure). Given the origin of this conflict, a better understanding of the data by both parties leads to satisfactory resolution. On the other hand, if the dispute stems from relational problems, wherein the worker stereotypes the payer as "out to get her" and "interested only in making money at the expense of quality care" and the payer views the worker as "uncooperative" and "inefficient," a more extensive intervention would be required to identify misconceptions, improve communications, and rebuild trust. …