Recommendation 8-1. Health care purchasers that offer enrollees a choice of health plans should evaluate and select one or more available tools for use in reducing selection-related incentives to limit the coverage and quality of M/SU health care. Risk adjustment, payer “carve-outs,” risk-sharing or mixed-payment contracts, and benefit standardization across the health plans offered can partially address selection-related incentives. Congress and state legislatures should improve coverage by enacting a form of benefit standardization known as parity for coverage of M/SU treatment.


Recommendation 8-2. State government procurement processes should be reoriented so that the greatest weight is given to the quality of care to be provided by vendors.


Recommendation 8-3. Government and private purchasers should use M/SU health care quality measures (including measures of the coordination of health care for mental, substance-use, and general health conditions) in procurement and accountability processes.


Recommendation 8-4. State and local governments should reduce the emphasis on the grant-based systems of financing that currently dominate public M/SU treatment systems and should increase the use of funding mechanisms that link some funds to measures of quality.

Finally, despite how much is known about ways to improve the quality of M/SU health care, knowledge gaps remain. In particular, there has been much less research to identify how to make treatments effective when given in usual settings of care and in the presence of common confounding problems (such as comorbid conditions and social stressors) than research to determine the efficacy of specific treatments under rigorously controlled conditions. In addition, there are many gaps in knowledge about effective treatment, especially for children and adolescents, and there is a paucity of information about the most effective ways to ensure the consistent application of research findings in routine clinical practice. To fill these knowledge gaps, the committee recommends the formulation of a coordinated research agenda for quality improvement in M/SU health care and the use of more-diverse research approaches.

Recommendation 9-1. The secretary of DHHS should provide leadership, strategic development support, and additional funding for research and demonstrations aimed at improving the quality of M/SU health care. This initiative should coordinate the existing quality improvement re-



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