Through PMHM’s Professionally Guided Care ProgramSM, doctorate psychologists perform all management functions, from referring patients to outpatient care through precertifying and managing inpatient admissions. PMHM’s high level of review expertise is not found in other managed care companies. This is the key difference which sets PMHM apart from its competitors.
History of the Industry. To understand why PMHM produces such superior results, it is important to understand how most firms review care.
Until now, nurses and managed care have always gone together. When employers chose a managed care firm, it went without saying that nurses performed the vast majority of management functions. This nurse management became possible with the invention of computers and DRGs. The DRG system, which provided specific lengths of stay for various types of medical problems enabled a nurse to sit in front of a computer and use DRG-related spreadsheets to precertify inpatient care.
This nurse/DRG system worked well for general medical problems. For example, if a patient was diagnosed with an appendicitis or heart attack, the diagnosis was clear cut and the DRG-generated number of inpatient days was effective. With mental issues, however, the DRG system is not so clear cut. This is because in the mental health area, misdiagnosis is prevalent. Left uncorrected, misdiagnosis can keep patients in a revolving door of ineffective care which can cost the benefit plan thousands of dollars and last for years.
Some behavioral health firms tried to address this problem by using “psychiatric” nurses as reviewers. The term “psychiatric” nurse is really a misnomer as there is actually no training or certification program in psychiatric nursing. A psychiatric nurse is an RN or LPN who has spent time working in a psychiatric unit. This would be like calling a hospital orderly who had worked on a psych unit a “psychiatric orderly.”
The problem with nurses reviewing mental health care is that, since each patient’s case is so different, DRGs for problems like schizophrenia or depression are not widely used nor can they be applied appropriately in each case. Also, a significant number of patients are misdiagnosed in the first place.
In the behavioral health field, there is no clear-cut understanding that a patient with a certain type of problem should be treated in a certain way. For example, one provider may believe that a given depressed patient can be effectively treated in outpatient therapy while another provider may believe the same patient will require a thirty-day inpatient program. The cost of these two different treatment regiments can differ tremendously – from about $500 for outpatient treatment to $30,000 for an inpatient stay. Because of these differences or opinion, nurse reviewers tend to “err on the safe side” and authorize more care.
PMHM is the only national managed care firm which uses doctorate psychologists to make all management decisions. PMHM uses psychologists, instead of psychiatrists, because psychologists are the most broadly trained in testing and diagnosis. This expertise is useful because in the mental health area, misdiagnosis is common which can result in years of expensive, ineffective treatment. PMHM saves the benefit plan money in the best way possible, by providing the clinical expertise to help patients get better.
For a comparison of PMHM’s results versus other managed care firms, click here.
