Recent publications have outlined a number of actions taken by academic institutions to respond to the radical transformation of healthcare due to the growth of managed care (1—3). Organizational consolidations and alliances, along with newly created clinical and research programs designed to satisfy managed care, are examples of this transformation (4—11). Academic psychiatry has to respond to various competing forces. These include the need for medical schools to create seamless clinical care initiatives for medical payers, the external demands of the payers of managed behavioral health care, and declining reimbursement. The ability of academic departments of psychiatry to create the structures and processes necessary to achieve the most beneficial clinical and fiscal outcomes is essential for their survival in this new era of healthcare.
Despite excellent commentaries in the literature regarding the ethical, practical, and philosophical implications of managed care with respect to academic psychiatry, limited information is available on academic psychiatry's capacity to respond to managed care requirements (12—18). If such a database were available, academic departments could share their information and begin the process of discovering best practices on a regular basis. An early effort by Moffic and colleagues (19) in the early 1990s surveyed the managed-care readiness of academic psychiatry and provided a baseline from which future surveys could be conducted. The study found limited interest and efforts in regard to managed care. With no established benchmarks, academic psychiatry has been unable to compare and evaluate managed behavioral healthcare programs. The present study proposes to survey the managed-care readiness of academic psychiatry and provide a baseline with which future surveys could be compared.
The survey was designed by two of the authors (NAD, ASD). After the survey was developed, a website (bstpractice.com) was established, such that potential respondents could log on to the World-Wide Web and enter their responses. Details of the programming and the tools used to develop the website survey have been published elsewhere (20, 21). Initially, two chairs of psychiatry (KA, AT) field-tested the instrument for ease of use and utility. Both chairmen found the survey to be acceptable and thought the answers could be useful to academic psychiatry. The 25-item questionnaire is divided into three sections: The first part has 13 questions related to organization structure and programs currently available in academic psychiatry. The second part includes five questions concerning the use of quality- and performance-improvement initiatives, and the remainder of the questions concern the information-systems capacity of academic psychiatry. The website was completed in the fall of 1996. The chairmen of departments of academic psychiatry across the country were notified via e-mail and postcard invitations. Consultation as to how to reach chairs of psychiatry was provided by the organization of chairs of psychiatry. Respondents from 35 departments logged on to the survey.
Characterization of Departments Responding to the Benchmarking Survey
Responses came from institutions in 23 states and one Canadian province. The states spanned all corners of the nation, from Connecticut to Florida and from Washington to Nevada. The state with the highest number of respondents was Texas, with four respondents (11.1%); followed by Michigan and Pennsylvania, each with three respondents (8.3%); then Kentucky, New York, and New Jersey, each with two respondents (5.6%). The remaining states have one respondent each.
Those who filled out the survey hold a variety of positions, with a variety of titles for the respondents. The most common title is Department Chair (40%). Other titles are Vice Chair, Department Administrator, and one Administrative Assistant.
Part One of the survey (t1) examines the organizational structure of departments of psychiatry and their potential capacity and position to assume a role in the managed-care arena. Several of the departments share ownership or control of a Health Maintenance Organization (HMO) or health plan with a nonprofit entity (28.6%), a government entity (8.6%), or a for-profit entity (5.7%). Three of the responding departments (8.6%) operate their own HMO, or health plan program. The medical schools to which the departments are affiliated have a substantial role in the ownership and management of HMOs or health plans. Ten medical schools (28.6%) share ownership or control of an HMO or health plan with a nonprofit entity, 2.9% with a government entity, 11.4% with a for-profit entity, and 25.7% operate their own HMO or health plan.
Academic departments are very active in the delivery of clinical services. All of the responding departments provide clinical services in outpatient care, 97.1% offer clinical services in an inpatient setting, and 94.3% offer services in emergency or evaluation services. Clinical services are offered in Day Treatment centers (88.6%), Intensive Outpatient Services (82.9%), Partial Hospitalization (80%), and Work-Site or Employee Assistance (65.7%). Few academic departments provide clinical services in residential treatment (40%), group home (20%), and/or home health care (22.9%). A large percentage of departments play a role in the clinical services of Community Mental Health Centers (94.3%), nonprofit care (85.7%), the Veterans Administration (60%), local government-owned settings (51.4%), university-owned (85.7%), state-owned (82.9%), primary care (71.4%), and for-profit operations (40%).
Part Two of the survey (t2) examines the readiness and capacity of academic departments to meet the requirements of managed care. A majority of the departments (71.4%) say that they have a defined strategy for responding to managed care. Sixty percent have a designated curriculum for residents in the area of managed care. A majority (68.6%) of departments have staff or faculty designated for managed care operations. Fewer than half (37.1%) have a separate organizational or legal structure that supports the capacity for managed care contracting; however, they may operate through larger hospitals, medical centers, or medical school contract mechanisms.
Many departments hold Provider contracts for managed-care services in preferred provider organizations (PPOs) and HMO settings (88.6%). Almost half (48.6%) of the departments hold contracts for some type of utilization review. Fewer departments hold delegated contracts for managed-care services, including quality improvement/management (40%), full risk/capitation (45.7%), at-risk inpatient services (40%), credentialing (31.4%), and case rate contracts (31.4%). The Department Chair/Designee rarely (17.1%) has signature authority for managed-care contracts. For over half of the respondents, the clinical enterprise and/or the medical school dean/designee holds principal signature authority.
The survey also examines the structure and process of the Department's quality-management systems (t3). This is an integral part of the preparation for managed-care contracts. Departments already conduct a broad spectrum of surveys. Over half of departments responding indicate they survey adults (65.7%), children (57.1%), adolescents (60%), and geriatric populations (54.3%). Fewer than half of these departments (40%) survey family members of mentally ill patients. A majority of departments conduct some type of patient satisfaction surveys, with 80% of respondents conducting Outpatient Care surveys and 79.4% conducting Inpatient Setting surveys. A little over half of the respondents (51.5%) conduct Emergency/Evaluation Services surveys and Intensive Outpatient Services surveys (51.7%). Satisfaction is also measured in Partial Hospitalization (50%), Work-Site or Employee Assistance (47.8%), Day Treatment (48.4%), and Residential Treatment programs (23.1%), group homes (28.6%), and home health care (12.5%). Although a majority of departments have formal mechanisms for surveying satisfaction of residents (65.7%), fewer than half of them survey the satisfaction of faculty (48.6%), primary care clinicians (37.1%), non-physician clinicians (34.3%), research subjects (22.9%), carve-out behavioral managed care staff (20%), voluntary faculty (20%), and medical insurance companies (8.6%).
Most respondents (88.6%) of the departments express the need to comply with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, yet only 42.9% of the departments' report card systems currently comply with the JCAHO Indicator Management System. Fewer than half (45.7%) seek to comply with the National Committee for Quality Assurance (NCQA) requirements, and only 25.7 % seek to comply with NCQA HEDIS® (Health Plan Employer Data and Information Set) requirements. The survey does not evaluate their preparation on accountability to other accreditation systems.
Information systems (t4) are the cornerstone of effective and efficient operations and the capacity to meet the requirements of managed care. All responding departments are equipped with IBM PC-compatibles and use Microsoft applications for business and office functions. All departments also use e-mail, and a vast majority have Internet access (97.1%) and a network/terminal system (94%). Eight percent even have their own web page. From the perspective of care management, 65.7% of departments utilize an information system that supports census or clinic management, 34.3% support capitation contracts management, 25.78% support care/case management, and only 8.6% support report card management. In the area of managed-care functions, 51.49% of departments have an information system that supports enrollment and eligibility; 54.3% have information-systems support for claims adjudication. Fewer than half of the departments' information systems support provider profiling (40%), credentialing (45.7%), referral/utilization (40%), custom reporting (37.1%), and outcomes evaluation (28.6%).
This study represents the first use of the World Wide Web to conduct a benchmarking survey of academic medicine and, specifically, academic psychiatry. This technology can be useful for maintaining ongoing benchmarking initiatives. It provides for easy survey access and rapid turnaround of results and new trends. Despite its ease of use, only 35 academic departments responded to the survey. Because it is the first web survey effort, no benchmarks exist to determine if the response rates are consistent with other web survey efforts in healthcare. The response rate is similar to mail surveys, and the results should be interpreted with caution. Also, the survey used a yes/no choice format and did not allow comments to be included. Initial field testing of the survey, however, revealed that it was easy to understand and use. Cognitive interviewing of the chairmen who reviewed the survey was not done. Cognitive interviewing would have revealed whether the respondents were interpreting each question in a similar manner and in a manner consistent with the intent of the survey. Future efforts will be needed to enhance the reliability and validity of web-based surveys. Nonetheless, the results suggest that academic psychiatry is beginning to position itself for success in a rapidly changing managed-care environment.
Fewer than half of the departments have a legal entity or the structures necessary to contract with managed-care organizations. At the same time, larger entities within the medical school may do such contracting, rather than the department itself. Also, risk-based contracting occurs in less than 40% of academic psychiatry. At a time when 110 million citizens are covered by managed behavioral health care, academic departments desperately need the organizational and managed-care vehicles to survive and compete as business entities (21).
Academic departments provide a full range of behavioral health services in both inpatient and outpatient settings. Long-term settings such as group homes and residential treatment settings are usually not operated by academic departments. This part of the continuum of care may be an area where academia can develop partnerships for the future.
At another level, academic psychiatry has embraced measurement of quality and satisfaction in particular. The majority of the departments responding conduct satisfaction surveys in areas such as outpatient care, inpatient setting, and emergency/evaluation services. At best, this investigation is tied to inpatient accreditation compliance. Outcome evaluation is not yet a significant part of the culture of academic psychiatry. This must be examined and changed in the new era of accountability to include regulatory mandates by voluntary accreditation bodies.
Information Systems, the infrastructure that allows a business to operate a managed-care enterprise, is emerging in academic psychiatry. About half of the departments report a capacity for enrolling members and adjudicating claims. These are essentially "back office" functions. Information systems are used to a lesser extent to support other functions, like case management, credentialing, and provider profiling. The lack of a comprehensive managed-care information system could be due to both the expense and the operational readiness of academic psychiatry to enter into managed-care services. Another reason could be that some departments and medical schools have collaborations with existing managed-care organizations that already have the necessary information-systems infrastructure. A more detailed survey and evaluation would shed light on these and other issues.
In conclusion, the results of this first Internet-based survey provides a broad overview and highlights the current status of a number of academic departments of psychiatry with respect to their readiness for managed care. Medical schools and academic departments are partnering with managed-care organizations and are providing a diverse array of behavioral health services. Quality measurement currently is limited to satisfaction, and information infrastructure is focused on back-office functions. Academic psychiatry has clearly recognized the need to "manage" and provide care. Existing deficiencies however, need to be addressed in rapid fashion before academic psychiatry can thrive in the contemporary healthcare environment.