Evidence-based practice in managed care: more propaganda than reality? (Special Report: Evidence-Based Practices).

The behavioral healthcare field has long acknowledged that research findings as to what interventions are most effective frequently do not translate in actual practice. Interventions that are reportedly effective in controlled studies are extremely difficult to introduce in an agency or practice setting. Even though much is being done to encourage clinicians to adopt a more evidence-based approach, the behavioral health field remains plagued with huge variations in clinical practices, persistent use of interventions with very limited effectiveness, and a painfully slow introduction of interventions with better-known effectiveness.

There still seems to be an abundance of practitioners who want to cling to the conjecture that our interventions are "generically effective" when there are probably occasions when our rate of success is no greater than spontaneous remission. The simple concept that interventions provided by behavioral health professionals should be based, as closely as possible, on evidence from the best available research would seem uncontroversial. What is perhaps worthy of scrutiny are some of the ways in which the concept is being implemented.

Managed care's advertised solution

One important solution put forth by the managed behavioral healthcare industry is to encourage network providers to follow specific evidence-based practice (EBP) guidelines and reduce ineffective variations in treatment, cut costs, and enhance quality. Toward this end, numerous EBP guidelines have been disseminated to thousands of network providers by different managed behavioral healthcare organizations (MBHOs).

In theory, these EBP guidelines provide a foundation for informed clinical decision-making by creating access to treatment protocols based on the compilation and analysis of relevant scientific research. Clinical choices, then, are nor solely justified based on "insight, preferences, or practice wisdom" but rather on data from published journal articles, research reports and expert consultation.

A recent study (Sharar D, Huff S, and Ackerson B (2003) Organizational Ethics in Managed Behavioral Healthcare: Perspectives from Executives and Managers. Scheduled for publication in Critical Issues in Human Sciences and Services) suggested that despite claims by MBHOs that their research infrastructure has generated reasonably valid and sound EBP guidelines, utilization managers working in MBHOs routinely make clinical judgments through a process they are not able to fully articulate, occasionally relying on decision tools that are subjective, political and, at times, crude.

The study consisted of qualitative interviews with 27 executives and managers working in MBHOs in all regions of the U.S., and examined the organizational ethical issues faced in managed behavioral healthcare. When asked how clinical-necessity criteria and protocols were derived, the majority of participants described an amalgam of documents that were created, borrowed or adapted from expert opinion and research studies that were assembled and promulgated in a way that was not solely explicit.