Different types of evidence As discussed earlier, M/SU health care has often relied on evidence generated by quasi-experimental studies rather than randomized controlled trials. Some performance measures that are deemed valid by M/SU stakeholders may therefore be less credible to performance measurement stakeholders in the general health care sector.
Unclear locus of accountability The separation of the delivery of M/SU and general health care discussed earlier impairs performance measurement in two ways. First, it can create confusion as to whether a given performance measure can be used because it is unclear to whom the measure should apply. There is confusion about the entity accountable for care quality when care can be delivered through multiple delivery arrangements (e.g., primary or specialty care, general or carve-out health plans, school-based programs). For example, the HEDIS performance measures addressing M/SU health care apply to general health plans seeking accreditation, but not to managed behavioral health care organizations.16
Another problem caused by the separation of M/SU and general health care, as well as by the separation of mental and substance-use care, relates to access to data. To produce many performance measures, data on the patient’s entire illness—from detection through ongoing treatment—are needed. When patients are served by entities separate from their general health care plan or from each other, such as carved-out managed behavioral health plans, employee assistance programs, school-based health care services, and child welfare agencies, the ability to link necessary data is impaired, making many performance measures infeasible (Bethell, 2004; Garnick et al., 2002). Moreover, the voluntary support sector is not typically viewed as formal treatment despite the fact that self-help groups such as Alcoholics Anonymous and other types of peer counseling play an important role in recovery for many individuals with M/SU illnesses. Indeed, the voluntary support sector has been characterized by a lack of data and, in some cases, a commitment to anonymity (Horgan and Garnick, 2005).
As articulated in a paper on performance measurement for child and adolescent M/SU health care that was commissioned by the committee (Bethell, 2004:30):
Perhaps one of the most significant findings … is the lack of coordination in the field among the many actors engaged in measurement development in the area of mental and behavioral health care for children and adolescents. It seems new activities evolve daily with no coordinating center to ensure activities address priority needs and strategic goals as