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OCR for page R1
SUMMARY
MANAGING
MANAG E D CARE
QUALITY IMPROVEMENT IN
BE HAVIORAL H EALTH
Margaret Ecimuncis, Richard Frank, Michael Hogan,
Dennis McCarty, Rhoncia Robinson-Beale,
and Constance Weisner, Editors
Committee on Quality Assurance and Accreclitation Guiclelines
for Managed Behavioral Health Care
Division of Neuroscience and Behavioral Health
Division of Health Care Services
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C. 1997
OCR for page R2
NATIONAL ACADEMY PRESS · 2101 Constitution Avenue, N.W. · Washington, DC 20418
NOTICE The project that is the subject of this report was approved by the Governing Board of the
National Research Council, whose members are drawn from the councils of the National Academy of
Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the
committee responsible for the report were chosen for their special competences and with regard for
appropriate balance.
This report has been reviewed by a group other than the authors according to procedures ap-
proved by a Report Review Committee consisting of members of the National Academy of Sciences,
the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist
distinguished members of the appropriate professions in the examination of policy matters pertaining
to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional
charter responsibility to be an adviser to the federal government and its own initiative in identifying
issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of
Medicine.
Support for this project was provided by the Center for Substance Abuse Treatment of the Sub-
stance Abuse and Mental Health Services Administration, U.S. Department of Health and Human
Servlces.
This Summary is available in limited quantities from the Institute of Medicine, Division of Neu-
roscience and Behavioral Health, 2101 Constitution Avenue, N.W., Washington, DC 20418.
The complete volume of Managing Managed Care: Quality Improvement in Behavioral Health,
from which this Summary is extracted, is available for sale from the National Academy Press, Box 285,
2101 Constitution Avenue, N.W., Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313
(in the Washington metropolitan area), or visit the NAP's on-line bookstore at http://www.nap.edu.
Copyright 1997 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures
and religions since the beginning of recorded history. The image adopted as a logotype by the Institute
of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in
Berlin.
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COMMITTEE ON QUALITY ASSURANCE AND ACCREDITATION
GUIDELINES FOR MANAGED BEHAVIORAL HEALTH CARE
JEROME H. GROSSMAN* (Chair), Chairman anc3 Chief Executive
Officer, Health Quality LEC, Boston, MA, anc3 Scholar-in
Resicience, Institute of Medicine, National Academy of Sciences.
Washington, DC
ROBERT BOORSTIN, Mental Health Advocate, Washington, DC
JOHN J. BURKE, Executive Vice President, Value Behavioral Health
EAP Services, Falls Church, VA
M. AUDREY BURNAM, Senior Behavioral Scientist, Co-Director.
Drug Policy Research Center, RAND, Santa Monica, CA
BARBARA CIMAGLlO, Director, Illinois Department of Alcoholism
anc3 Substance Abuse, Chicago, IL
MOLLY JOEL COYE,* Executive Vice President, Strategic
Development, HealthDesk Corporation, Berkeley, CA
LYNNE M. DeGRANDE, President, DeGrancie anc3 Associates, Senior
Consultant, Employee Assistance Program, General Motors, Detroit,
MI
RICHARD G. FRANK, Professor of Health Economics, Department of
Health Care Policy, Harvard Medical School, Boston, MA
JOHN E. FRANKLIN, JR., Associate Professor of Psychiatry,
Northwestern University Medical School, Chicago, IL
MICHAEL F. HOGAN, Director, Ohio Department of Mental Health,
Columbus, OH
DENNIS McCARTY, Director, Substance Abuse Group, Institute for
Health Policy, Heller Gracluate School, Brancleis University,
Waltham, MA
J. MICHAEL McGINNIS, Former Deputy Assistant Secretary for
Health, Scholar-in-Resicience, Commission on Behavioral anc3
Social Sciences and Eclucation, National Acaclemy of Sciences,
Washington, DC Resigned from committee service, August 1996)
RHONDA J. ROBINSON-BEALE, Senior Associate Medical Director,
Coorclinatec3 Behavioral Health Management, Health Alliance
Plan, Southfielc3, M!
ALEX R. RODRIGUEZ, Vice President anc3 Medical Director, National
Account Consortium, Inc., Stamford, CT
~Member, Institute of Medicine.
. . .
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STEVEN S. SHARFSTEIN, President, Medical Director, and Chief
Executive Officer, The Sheppard Pratt Health System, Baltimore,
MD
DONALD L. SHUMWAY, Co-Director, Self-Determination for People
with Developmental Disabilities, Institute on Disability, University
of New Hampshire, Durham, NH
CONSTANCE WEISNER, Senior Scientist, Alcohol Research Group,
Western Consortium for Public Health and School of Public Health,
University of California at Berkeley, Berkeley, CA
Institute of Medicine Staff
MARGARET EDMUNDS, Study Director
CARRIE INGALLS, Research Associate
THOMAS WETTERHAN, Project Assistant/Research Assistant
AMELIA MATHIS, Project Assistant
TERRI SCANEAN, Administrative Assistant
EUGENE LEE, Student Intern
MOLLA DONALDSON, Senior Program Officer, Division of Health
Care Services
CONSTANCE PECHURA, Director, Division of Ne
Behavioral Health
IV
uroscience and
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Preface
introducing a report that aciciresses such a complex anc3 dynamic issue
as managed behavioral health care is a Jaunting task. The charge to the
Committee on Quality Assurance anc3 Accreditation Guidelines for Man-
agec3 Behavioral Health Care was to develop a framework to guide the
development, use, anc3 evaluation of performance indicators, accreclita-
tion stanciarcis, anc3 quality improvement mechanisms. The framework
could then be used to assist in the purchase and delivery of the most effec-
tive managed behavioral health care at the lowest appropriate cost for
consumers of publicly anc3 privately financed care.
There were numerous challenges in addressing this charge. The com-
mittee was operating in a rapidly changing environment in which mul-
tiple efforts by accreditation organizations, government agencies, con-
sumer groups, anc3 other interested parties were uncler way to develop re-
port carcis, performance indicators, anc3 other measures of behavioral
health care quality. The committee members chose to take an evicience-
basec3 approach to their task, but they found that the research base anc3 the
development of quality assurance anc3 accreditation stanciarcis are far less
advanced in behavioral health care than in other areas of health care.
Discussions among committee members clearly indicated a great cli-
versity in opinions anc3 experiences. The committee, however, believed
that its charge to create a framework for assessing quality assurance anc3
accreditation guidelines was best served by the development of recom
v
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v!
PREFACE
menciations broac3 enough to allow various stakeholcler groups to make
them more specific to their own needs anc3 circumstances, as appropriate.
This report fulfills this charge anc3 provides a framework that will be useful
anc3 enduring. In abolition, this report possibly for the first time weaves
together in a single place the many complex issues, concepts, anc3 chal-
lenges involved in assuring quality in behavioral health care in a way that
is accessible to a broac3 audience.
To accomplish its task, the committee began by developing the State-
ment of Principles incluciec3 in Chapter ~ of the full report. These prin-
ciples served to guide anc3 unite the committee anc3 are the outcome of
intensive discussion anc3 consensus-builcling across a rich diversity of views
anc3 perspectives.
As a primary care physician listening to the workshop presentations
anc3 deliberations, it was sometimes unclear to me whether or not mental
health anc3 substance abuse problems really presented unique challenges.
For example, many of the presentations anc3 discussions emphasized the
importance of viewing mental health anc3 substance abuse problems as
chronic, relapsing conditions that c30 not differ significantly from other
health problems, such as diabetes anc3 heart disease. Other presentations,
however, emphasized key differences, such as greater needs for integration
of services, a large percentage of substance abuse problems being dealt with
in the publicly funciec3 Meclicaic3 system, anc3 the emergence of so-called
"carve-out" companies providing behavioral health care, among other ex-
amples. Thus, the committee has tried throughout the report to uncler-
score a critical distinction between the unique aspects of the structure of
behavioral health care delivery and the nature of the disorders themselves, which
are not unique, but can range from a single episode of illness to chronic,
recurrent, anc3 disabling conditions.
From early on in its deliberations, the committee was cleterminec3 to
be scrupulous in separating eviclence-basec3 research results from informa-
tion based on current clinical strategies or best practices. Thus, the body of
the report includes findings that were rigorously grounciec3 in the research
literature. However, the committee felt that this report could not go for-
warc3 without expressing the strong clinical judgments that this is an excit-
ing time in research, that rapid progress is being made in the diagnosis and
treatment of behavioral health conditions, anc3 that there is an increasing
recognition of the importance of continuing care as a way to prevent or
ameliorate relapses.
Although the report covers a wide range of topics anc3 issues in this
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PREFACE
Vi!
field, it might be useful to highlight some of the issues that the committee
could not address fully and that will require ongoing consideration by feel'
eral anc3 state agencies, as well as a number of other stakeholcier groups.
Four key areas seem to be important areas for further work by others. First,
there are complex and often overlapping systems of regulation and ac-
creclitation, which result in different data requirements, specifications, anc3
timetables. In abolition, there are compelling needs to ensure the quality
anc3 integrity of the various measures used by many different organizations.
This complexity presents real challenges to purchasers, consumers, pro'
vipers, anc3 practitioners of behavioral health care. This report describes
the complexity anc3 presents general recommendations to be consiclerec3
by the variety of regulatory agencies anc3 accreditation organizations (e.g.,
the utility of external audits anc3 quality improvement mechanisms).
Whether or not the current system requires mollification anc3 how such
mollification should be approached, however, was beyond the scope of our
work.
The second key area involves questions regarding the analysis anc3 re'
porting of the many different types of quality assessment (e.g., report carols,
patient satisfaction measures, anc3 other evaluations) anc3, further, how to
use such measures to develop accurate anc3 appropriate case~mix anc3 risk
adjustment models. To aciciress these questions, the committee believes
that further development of analytical tools is necessary anc3 that this evi'
clence base needs to be expanclec3 before cletailec3 recommendations can be
macle. In abolition, development of such tools will require collaboration
among various components of the public anc3 private sectors. The public'
anc3 private~sector entities involved might find it fruitful to consider ways
to foster these collaborations.
Third, there is a general need to develop strategies to aciciress the com'
plexities of the Meclicaic3 population, particularly as they relate to people
with mental health anc3 substance abuse problems anc3 to the Revolution of
responsibility for this population from the federal government to the states.
A comprehensive survey of the states anc3 an analysis of the specific needs
of the mental health anc3 substance abuse segment of Meclicaic3-coverec3
health care anc3 the variety of needs across states were beyond the
committee's charge. Yet, this theme was expressed at many of the com'
mittee's workshops anc3 in its deliberations, anc3 further work seems neces'
sary to understand the complex needs of this population, particularly as
they relate to strategies to integrate services across social services agencies
and health care proviclers.
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. . .
vile
PREFACE
The fourth area relates to the variety of health care practitioners, of'
ten working simultaneously, who are involved in treating mental health
anc3 substance abuse problems. Clearly, tensions exist among some of these
groups of practitioners, but there is also a great need to integrate care across
the various disciplines when a patient is being treated by a team of practi'
tioners. This situation is an excellent example of a systemic problem that
contributes importantly to the fragmentation of services cliscussec3 in the
report anc3 that this committee could not solve. However, the variety of
practitioners involved also presents special problems for measuring quality
in managed behavioral health care, anc3 these problems could benefit from
further research to design specific approaches to handle the tensions anc3
to aciciress the need for integration of treatment services.
The entire health care system is changing rapidly, anc3 behavioral
health care is no exception. During the spring anc3 summer months of 1996
when the committee met, Congress cieliberatec3 anc3 then passed a com'
promise mental health parity bill, consumer groups challenged the capac-
ity of accreditation organizations to measure quality, anc3 researchers re'
ported that psychotherapy hac3 been found to produce changes in brain
function similar to those seen with medications. While the report was be'
ing reviewed, President Clinton announced the formation of a federal ad'
visory commission on the quality of health care. Thus, the issues consic3'
erec3 by the committee are timely anc3 seem to reflect some fundamental
policy questions, some of which will continue to be clebatec3 over the next
clecacle anc3, possibly, longer.
As one who has been fortunate to participate on a number of Institute
of Medicine committees, ~ must close with a personal statement. The sub'
ject matter, the committee anc3 its generous participation in lively anc3
informative meetings as well as in writing the report, anc3 the {OM staff
particularly the study director, who kept the work on track anc3 synthe'
sized anc3 balanced the multiple streams of input have macle this effort
one of the most satisfying in which ~ have participated in the past 15 years.
Jerome Grossman, M.D., Chair
Committee on Quality Assurance and
Accreditation Guidelines for
Managed Behavioral Health Care
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Acknowledgments
The committee would like to acknowledge the contributions of many
inclivicluals and organizations to the committee's work.
The committee expresses cieep appreciation to all the inclivicluals and
groups who contributed to the public workshops. The speakers in the work-
shops were Don Austin, John Bartlett, Linda Bresolin, Ray Bridge,
Catherine Brown, Reginald Cedar Face, Robert Cole, William Dennis
Derr, Elizabeth Edgar, Robert Egnew, Michael Faenza, Daniel Fisher, Julia
Puebla Fortier, Ann Froio, Donald Galamaga, Susan Goldman, Sybil
Goldman, Sarah Gotbaum, Elizabeth Haciley, Laura Lee Hall, Judith
Hines, Michael Jeffrey, Linda Kaplan, Randall Maciry, Ron Manclerscheic3,
David Mee-Lee, Raphael Metzger, Margaret O'Kane, Peter Panzarino,
Mark Paris, Mark Parrino, Geoffrey Reed, Gwen Rubinstein, Paul Schyve,
Golnar Simpson, Tim Slaven, Sarah Stanley, Tom Trabin, Robert Valciez,
Rita Vanclivort, and Grace Wang. Many inclivicluals who were not speak-
ers also participated by asking the workshop speakers Questions. and they
are listed in Appenclix D.
~,
The committee thanks Don Steinwachs and Thomas McLellan and
his colleagues Mark Belcling, James McKay, David Zanis, and Arthur
Alterman for contributing their papers, which were used by the commit-
tee in preparing this report and which appear as Appenclixes to this report.
The committee expresses appreciation to Don Detmer and Ed Perrin,
who servecl, respectively, as liaisons to the Institute of Meclicine (IOM)
IX
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x
ACKNOWLEDGMENTS
Board on Health Care Services anc3 the National Research Council's Com-
mittee on National Statistics (CNSTAT).
The committee is particularly grateful to the members of the liaison
panel, who raised many questions for the committee's consideration anc3
helped to identify materials for the committee's review. All of the mem-
bers are listed in Appendix E. The members who were especially active in
responding to requests for information were Linda Bresolin, Peggy Clark,
Judith Emerson, Elizabeth Haciley, Judith Hines, Linda Kaplan, Anne
Kilguss, Yvonne Lewis, Mark Paris, Mark Parrino, Clarke Ross, Gwen
Rubinstein, Paul Schyve, Claire Sharcia, Tom Trabin, Jeanne Trumble,
Robert Valclez, anc3 Margaret Van Amringe. Organizations that submitted
written comments for the committee's review are listed in Appendix F.
The committee is grateful to several inclivicluals who proviclec3 techni-
cal comments on preliminary cirafts of sections of the report. They include
Gary Chase, Peggy Clark, Denise Dougherty, Lynn Ethereclge, Joe Frisino,
Susan Goldman, Judith Katz-Leavy, Kathleen Lohr, Hal Luft, David
Mactas, Ron Manclerscheic3, Clarke Ross, Hector Sanchez, Eugene
Schoener, Paul Schyve, Claire Sharcia, Lisa Simpson, anc3 Tim Slaven.
The committee could not have accomplished its task without the in-
sightful anc3 tireless support of the study director, Margo Ecimuncis. Dr.
Eclmuncls' extraordinary skills in planning and managing the study, imagi-
native guidance of the committee's activities, anc3 writing or editing nu-
merous sections of the report proviclec3 an anchor for the committee
throughout the study.
Other members of the IOM professional staff also proviclec3 invaluable
help. Constance Pechura cievelopec3 the idea for the study with the spon-
sor anc3 proviciec3 guidance throughout, including descriptions of the IOM
process anc3 identification of resources anc3 materials. Molla Donaldson
attenclec3 committee meetings anc3 reviewed ciraft sections of the report.
Marilyn Field was responsive to many questions anc3 reviewed ciraft sec-
tions of the report. Linda Bailey anc3 Jane Durch helped to coordinate this
study with the IOM study on public health performance monitoring, as
slid Jeff Koshel, study director for the CNSTAT effort on performance
partnership grants.
The professional staff were supported by the efforts of Carrie Ingalls,
research associate; Thomas Wetterhan, project assistant/research assistant;
Amelia Mathis, project assistant; Terri Scanlan, aclministrator; and Eu-
gene Lee, a summer student intern from the Massachusetts Institute of
Technology. Other IOM and National Acaclemy of Sciences staff who
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ACKNOWLEDGMENTS
Xt
were helpful at a variety of stages include Carolyn Fulco, Carlos Gabriel,
Kate-Louise Gottfriec3, Linda Kilroy, Lauren Leveton, Cathy Liverman,
Luis Nunez, Dan Quinn, Mary Lee Schneiciers, anc3 Andrea Solarz. During
report review, Claudia Carl anc3 Mike Eclington proviciec3 valuable direct
tion anc3 technical assistance. The extensive commentary anc3 suggestions
macle by the copy editor, Michael Hayes, are gratefully acknowlecigec3.
Finally, support for this study was provided by the U.S. Department of
Health anc3 Human Services, Substance Abuse anc3 Mental Health Ser'
vices Administration (SAMHSA), anc3 its three centers: the Center for
Substance Abuse Treatment (CSAT), the Center for Mental Health Ser'
vices (CMHS), anc3 the Center for Substance Abuse Prevention (CSAP).
David Mactas, the Director of CSAT, the leac3 agency for the study, cle'
scribed the sponsor's goals for the study at the committee's first meeting.
For their helpful responses to the staffs inquiries anc3 requests throughout
the study, the committee thanks Macly Chalk, Director of Managed Care
Initiatives at CSAT anc3 the government's project officer; Eric Gopleruc3,
Director of SAMHSA's Managed Care Initiative; Jeff Buck, Acting Direct
tor of the CMHS Office of Policy anc3 Planning; Nancy Kennedy, Man'
aged Care Coordinator for CSAP; anc3 Ron Manclerscheic3, Chief of the
Survey Analysis Branch for the CMHS Division of State anc3 Community
Systems Development.
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Contents
SUMMARY
introduction, 1
Description of the Study, 6
Statement of Principles, 9
Terminology Used in This Report, 13
Trencis in Managed Care, 14
Challenges in Delivery of Behavioral Health Care, 17
Structure, 23
Access, 26
Process, 28
Outcomes, 34
Findings and Recommendations, 36
Concluding Observations, 52
References, 52
The contents of the entire report,
from which this Summary
is extracted, are listed below.
ACRONYMS
SUMMARY
. . .
x`~`
1
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xlv
1 INTRODUCTION
Terminology Used in This Report
Consumers and Families
Practitioners
Purchasers
The Managec3 Care Industry
Statement of Principles
Organization of the Report
2 TRENDS IN MANAGED CARE
The Changing Health Care System
Concerns with Managec3 Care in the Public Sector
Behavioral Health in the New Marketplace
Health Care Quality
Prevention
Quality Improvement and Quality Assurance
Ethical Issues in Managec3 Behavioral Health Care
Summary
3 CHALLENGES IN DELIVERY OF BEHAVIORAL
HEALTH CARE
Extent and Impact of Behavioral Health Problems
The Role of Primary Care
Special Issues for Quality in Behavioral Health Care
Developments in the Private Sector
Quality and Consumer Protection Challenges
Variability at the State Level
Historical Perspective on Systems
Summary: System Integration
4 STRUCTURE
Practitioner Issues
Meclicaicl
Medicare
Substance Abuse Service Systems
Mental Health Treatment
Wraparouncl Services
Managec3 Behavioral Health Care Industry
CONTENTS
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CONTENTS
XV
Workplace Services
U.S. Department of Defense anc3 U.S. Department of Veterans Affairs
Care anc3 Services for Children anc3 Adolescents
Care anc3 Services for Seniors
Indian Health Service
Cultural Competence
Rural Health anc3 Managed Care
Summary of Structural Issues
5 ACCESS
Importance of Assessing Access
Measures of Access
Need anc3 Access
Needs of Special Populations
Measuring Access to Services Within Managed Care Organizations
Summary
6 PROCESS
Quality anc3 Accountability
Quality Management in Behavioral Health Care
Performance Measurement in the Public Sector
Accreditation
Information Infrastructure for Quality Measurement
Role of Government in Quality Assurance
Summary
7 OUTCOMES
Definitions of Success
General anc3 Specific Measures of Outcomes
Links Among Structure, Process, anc3 Outcomes
Performance Indicators as Outcomes Measures
Efficacy anc3 Effectiveness
Outcomes anc3 Quality Improvement
Criteria for Evaluating Outcomes Measures
Summary
8 FINDINGS AND RECOMMENDATIONS
1. Structure and Financing
2. Accreditation
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xv!
3. Consumer Involvement
4. Cultural Competence
5. Special Populations
6. Research
7. Workplace
8. Wraparound Services
9. Children and Adolescents
10. Clinical Practice Guidelines
11. Primary Care
12. Ethical Concerns
GLOSSARY
APPENDIXES
CONTENTS
A Biographies
B Commissioned Paper: Can the Outcome Research Literature
Inform the Search for Quality Indicators in Substance
Abuse Treatment?, A. Thomas McLellarr, Mark Be7Jir~g,
lames R. McKay, David Zarris, arid Arthur I. Attermarr
C Commissioned Paper: Consumer Outcomes and Managed
Behavioral Health Care: Research Priorities
Dorrald M. Steir~quachs
D Public Workshop Agendas and Participants
E Liaison Panel Members
F Organizations that Submitted Written Statements to the Committee
INDEX
