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Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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4

Structure

Structural measures of quality refer to the resources and capacity of a delivery system to deliver care, including the qualifications of practitioners, the nature of the services and facilities, and certain organizational factors. For practitioners, structural information concerns specialty, licensure, and certification, as well as practice style and setting. The chapter begins with a discussion of these practitioner issues. For facilities and institutions, structural measures include services, size (e.g., number of patients served), location (e.g., number of clinics), licensure and accreditation status, and physical characteristics, such as computer capacity. Traditionally, structural information provides the foundation for quality assurance and accreditation programs.

Analysis of the structure of the behavioral health care service systems requires a review of both public and private service systems for both substance abuse and mental illness. As discussed in Chapter 3, the behavioral health delivery systems involve a complex combination of public and private financing as well as public and private practitioners of care. Public-sector services are financed either with state and federal appropriations or through Medicaid and Medicare coverage, which are discussed first. Next, the public service systems for substance abuse and mental health are examined. Private systems of care have different structures but coexist and often overlap with public-sector services. Workplace service systems (e.g., employee assistance programs [EAPs]) and managed behavioral health care strategies, which have had a stronger influence in the private sector, are also reviewed.

Federally supported service systems developed by the U.S. Department of De-

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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fense (DOD) and the U.S. Department of Veterans Affairs (VA) share characteristics of both the private- and public-sector systems of care but represent separate and distinct service systems. Finally, service systems for distinct populations are examined: children, the elderly, Native Americans, and consumers in rural areas.

PRACTITIONER ISSUES

In the field of mental health, training tends to follow a professional, medical model, and state licensing, formal advanced education, and other credentials are typically required for reimbursement. The field consists of several types of professionals, including psychiatrists, psychiatric nurses, psychologists, clinical social workers, and marriage and family counselors. Many mental health treatments (e.g., marital and family counseling, treatment of eating disorders or depression, and group therapy) are offered by more than one type of professional. Medication can only be prescribed by psychiatrists and other physicians, so they sometimes provide medication management while other practitioners provide therapy and counseling. Relatively few health professionals are cross-trained as substance abuse treatment professionals, although this is beginning to change (Josiah Macy Jr. Foundation, 1995).

Substance abuse practitioners include individuals in all of the mental health practitioner categories, as well as substance abuse counselors. Originally, most substance abuse counselors were former substance abusers, because counseling others was seen as an integral part of the recovery model and process. Over the years, many people who are not in recovery have also entered the field. Currently, there is a growing emphasis on credentialing for all substance abuse counselors, and the number of hospital-based treatment units has increased substantially (SAMHSA, 1993). In general, the counseling approach relies on a recovery model and community-based self-help. Counselors are discussed further in a later section of this chapter, Drug Treatment.

Table 4.1 provides an overview of the credentialing involved for all practitioners involved with mental health and substance abuse problems. In managed care networks, an estimated 20 percent of practitioners are psychiatrists, 40 percent are psychologists, and 40 percent are social workers (Iglehart, 1996). The committee is aware of competition and tension among these types of practitioners for philosophical reasons that are largely beyond the scope of this report. However, the committee is not aware of any evidence from outcomes research that any one category of behavioral health practitioner is more or less effective than any other type of practitioner. Moreover, treatment philosophies and strategies vary substantially within professions, as well as across practitioner types, so research would need to take these differences into account.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

TABLE 4.1 Profiles of U.S. Practitioners in Behavioral Health Care

Professionals

Responsibilities

Workforce Population

Licensing and Credentialing

Practice Settings

Additional Information

Employee Assistance Professionals (EAPs) (EAPA, 1996)

Counsel employees on personal issues such as health, marital and emotional stress, and drug abuse, which can adversely affect job performance

Approximately 30,000-35,000 EAPs

More than 4,000 have become certified employee assistance professionals

Employee Assistance Professional Association (EAPA) provides certification of EAPs

Workplace

EAPs have no prescription-writing privileges

20,000 EAP training programs

Marriage and Family Therapists (AAMFT, 1996)

Counsel people with marital and family issues, as well as those with anxiety, depression, and conduct disorders

Approximately 50,000 marriage and family therapists

Various states (37) offer licensing, but there is no standardized licensing exam or certification

American Association for Marriage and Family Therapy (AAMFT) is lobbying all 50 states to establish standardized licensing and certification regulations for marriage and family therapists

Hospital, private (solo or group) practice, public clinic, and academia

No prescription-writing privileges granted

AAMFT has 76 accredited training centers

Nurses (ANA, 1996a, b)

Provide care, treatment, and other services, including prevention services, to all patients, including those with mental illnesses or substance abuse problems

Approximately 2.2 million registered nurses (RNs)

An estimated 1.9 million RNs

An estimated 19,145 RNs are state-certified psychiatric and mental health nurses

National Council of State Boards of Nursing licenses RNs and licensed practical nurses (LPNs) administered through state licensing boards

American Nurses Credentialing Center certifies nurses in approximately 20 different areas, including addiction and mental health

Hospital, private (solo or group) practice, public clinic, managed care, military, Veterans' Affairs (VA), correctional facility, academia, and home care

Prescription-writing privileges granted by state; only nurse practitioners (MNS) are usually granted such privileges

Physician Assistants (AAPA, 1996; NCCPA, 1996)

Provide support and assistance in the medical care of patients, ranging from surgical assistance to minor diagnostic services

Approximately 25,700 certified physician assistants (PAs)

Each state licenses PAs through the certification examination offered by the National Commission on Certification of Physician Assistants

Hospital, private (solo or group) practice, public clinic, managed care, military, VA, correctional facility, academia, and home care

Prescription-writing privileges granted by state

Primary Care and Other Physicians (AAFP, 1996; ASAM, 1994)

Provide diagnostic, treatment, and prevention services for patients with substance abuse problems and addiction, depression, anxiety disorders, and other behavioral problems

Approximately 2,790 American Society of Addiction Medicine (ASAM)-certified physicians in addiction medicine; most physicians certified by ASAM are psychiatrists, with a few from family and internal medicine

ASAM offers a non-American Board of Medical Specialties (ABMS) board certification in addiction medicine to its members; encourages other ABMS boards and the American Medical Association to consider offering certification in addiction medicine

American Academy of Family Physicians offers training in substance abuse treatment and prevention

Hospital, private (solo and group) practice, public clinic, managed care, military, VA, correctional facility, and academia

Prescription-writing privileges granted to all physicians (MDs and DOs)

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

Psychiatrists (ABPN, 1996; American Psychiatric Association, 1996)

Provide diagnostic, treatment, and prevention services to patients with mental illnesses and disorders, including substance abuse, through counseling and medical interventions

Approximately 30,000 certified psychiatrists

An estimated 1,067 are certified in addiction psychiatry

An estimated 1,579 are certified in child and adolescent psychiatry

National Board of Medical Examiners licenses all physicians through written examinations taken three times over the course of medical school and residency training

American Board of Psychiatry and Neurology (ABPN) of ABMS board certifies psychiatrists

Certification of added qualifications in addiction psychiatry and child and adolescent psychiatry is offered through ABPN

Hospital, private (solo or group) practice, public clinic, managed care, military, VA, correctional facility, and academia

Prescription-writing privileges granted to all physicians (MDs and DOs)

Psychologists (American Psychological Association, 1995, 1996)

Provide assessment, treatment, and prevention services to patients with mental illnesses and disorders and other individuals seeking counseling for a variety of problems, including substance abuse

Approximately 69,800 licensed and clinically trained psychologists

An estimated 950 are certified in substance abuse psychology

Association of State and Provincial Psychology Boards licenses psychologists through state licensing boards

American Psychological Association offers certification in several areas, including substance abuse

Hospital, private (solo or group) practice, public clinic, managed care, VA, correctional facility, and academia

No prescription-writing privileges granted, but initiatives are under way to granted limited privileges

Social Workers (AASSWB, 1996)

Counsel people with marital and family issues and behavioral health problems and promote access to social and community-based services

Approximately 300,000 social workers

American Association of State Social Worker Boards licenses social workers through state licensing boards

National Association of Social Workers offers national certification in various areas of social work

Hospital, private (solo or group) practice, public clinic, managed care, military, VA, and correctional facility

No prescription-writing privileges granted

Substance Abuse Counselors (NAADAC, 1996)

Provide diagnoses, guidance, and treatment for people addicted to drugs, with an emphasis on treatment of specific addictions

Approximately 40,000-50,000 substance abuse counselors

Only six states and the District of Columbia license alcohol and drug abuse counselors

National Association of Alcohol and Drug Abuse Counselors offers certification for those with no undergraduate- and graduate-level education; beginning in 1997, all counselors must have at least a baccalaureate degree to be certified

Hospitals, private practice, public clinic, military, VA, and correctional facility, and home visits

No prescription-writing privileges granted

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

MEDICAID

Background

Medicaid is a public health insurance program jointly funded and administered by federal and state governments. The Medicaid program was created in 1965 as part of the Social Security Act of 1965 to provide medical assistance for eligible poor and low-income populations. Between 1967 and 1995 the number of Medicaid recipients expanded from about 10 million to approximately 36.2 million people, which represents a 262 percent increase (NIHCM, 1996). Dependent children under age 21 accounted for almost half (17.6 million) of the total Medicaid recipients in 1995, an increase of 80 percent since 1985. As of June 1995, 32.1 percent of the 36.2 million Medicaid recipients were enrolled in managed care plans (HCFA, 1996a).

States administer the Medicaid program with guidelines and oversight by the federal Health Care Financing Administration. Financing comes from state funds, with the federal government providing a financial match based on a state's per capita income; the federal share ranges from 50 to almost 80 percent of the total for individual states (GAO, 1991). State Medicaid funding has doubled since 1988 and by 1993 represented 20 percent of many states' budgets (National Association of State Budget Officers, 1995).

Within federal guidelines, states can determine the type, amount, duration, and scope of services and establish eligibility requirements and rates of payment. To be eligible for federal funds, states must provide Medicaid coverage for most of the individuals who receive federally assisted income maintenance payments, including Aid to Families with Dependent Children (AFDC), Supplemental Security Income (SSI), and for some Medicare beneficiaries. States also can choose to provide Medicaid coverage for other “categorically needy” groups, such as aged, blind, or disabled individuals and certain infants and women. Medicaid-eligible children are covered by early and periodic screening, diagnosis, and treatment program (EPSDT), which emphasizes preventive and primary care and which requires comprehensive, periodic health assessments of physical and mental health development.

States can expand Medicaid eligibility to include “medically needy” groups such as children under age 18 or relatives of children other than parents caring for Medicaid-eligible children. Another Medicaid eligibility option addresses those individuals who have medical needs and expenses but may have too much income to qualify as “categorically needy.” In this eligibility option, medical or remedial care expenses can offset excess income, allowing individuals or families to “spend down” to Medicaid eligibility.

Medicaid costs depend on many factors, including the size of the eligible and enrolled population, the utilization and availability of services, and the needs of the population. Mandatory Medicaid services that cover mental health and sub-

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

stance abuse care include inpatient and outpatient hospital services, home health care services, nursing facility services, physician services, and EPSDT (Frank and McGuire, 1996; Manderscheid and Henderson, 1995; NIHCM, 1996). An estimated 15 percent of Medicaid funding goes to treatment for mental illness, including skilled nursing facilities, intermediate care facilities, state psychiatric hospitals, and general hospital psychiatric care (Taube et al., 1990). Medicaid supports nearly one-third of community-based mental health programs and is sometimes the only source of funding for community-based support and rehabilitation services (AMBHA and NASMHPD, 1995).

Administration of state Medicaid programs can be based in the health department or social service agency or in a separate agency, depending on whether the state emphasizes eligibility, medical services, or financial accountability. Cost-containment as the Medicaid agency 's primary goal can clash with the goals of the public mental health and substance abuse treatment agencies as they seek to maximize access to appropriate care for eligible individuals. Payment practices and the level of collaboration among agencies vary across the states, but Medicaid reform in the 1990s emphasizes managed care. A primary goal of Medicaid managed care is to control the growth in Medicaid expenditures while extending benefits to individuals who are uninsured.

Medicaid Reform Through Managed Care

The Congressional Budget Office estimates that Medicaid expenses will continue to increase at an annual rate of about 10 percent, reaching $260 billion by the year 2000 (CBO, 1995). Faced with increases in the number of recipients and the costs of their care, state and federal Medicaid officials have increasingly turned to managed care to control costs, estimating a 2 to 10 percent savings over fee-for-service care. The savings are projected to come from better coordination of care, shifts from inpatient to outpatient care, and increased emphasis on preventive care.

In 1991, 2.7 million (9.5 percent) of the 28.3 million Medicaid recipients were enrolled in managed care plans. As of June 30, 1995, almost one-third of Medicaid beneficiaries were enrolled in managed care plans (11.6 million of a total of 36.2 million beneficiaries) (HCFA, 1996a). Table 4.2 shows the increase in enrollments in Medicaid, as well as Medicare, from 1991 to 1995.

To implement Medicaid managed care initiatives, states can apply for one of two waivers: 1115 waivers allow program flexibility to research health care delivery alternatives, and 1115(b) “freedom-of-choice ” waivers allow managed care delivery systems within specific guidelines. As of August 1996, 49 states have received approval for waivers ranging from small-scale pilot programs to major Medicaid managed care programs, as well as welfare reform projects (HCFA, 1996a). Most of the state initiatives offer acute care, limited benefits for a basic plan and a carve-out for individuals with more intensive needs.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

TABLE 4.2 Medicaid and Medicare Total Populations and Number Enrolled in Managed Care (MC) Plans, 1991-1995

Year

Medicare Total population (in millions)

MC population (in millions)

Medicare Total population (in millions)

MC population (in millions)

1991

28.3

2.7

34.9

2.2

1992

30.9

3.6

35.6

2.4

1993

33.4

4.8

36.3

2.6

1994

33.6

7.8

36.9

3.1

1995

36.2

11.6

37.6

3.8

SOURCES: HCFA (1991, 1992, 1993, 1994, 1995, 1996a) and HIAA (1996).

To ensure the quality of Medicaid managed care, a Medicaid version of the Health Plan Employer Data Information Set (HEDIS) was developed in cooperation with the National Committee for Quality Assurance. Medicaid HEDIS was released in February 1996, and it adapted the performance measures used by more than 300 plans in the private sector. Medicaid HEDIS was incorporated into the draft version of HEDIS 3.0, which was released for public comment in October 1996, and which integrates measures that are relevant to both publicly and privately insured populations.

MEDICARE

The Medicare program was created by the 1965 Social Security Act as a form of universal health care coverage for all individuals who are age 65 and over and who are eligible for Social Security. In 1972, Medicare was extended to cover disabled individuals, who currently represent about 10 percent of the total Medicare population. Approximately 22 percent of the disabled individuals left the workforce because of mental illness (Lave and Goldman, 1990).

All elderly and disabled Medicare beneficiaries are enrolled in Part A (hospital insurance), which is financed mainly through a payroll tax on earnings that are covered under the Social Security Act (IOM, 1990). Beneficiaries may also voluntarily enroll in Part B (supplementary medical insurance), which covers physician services, including visits in the home, office, and hospital. Part B is financed through a monthly premium that is deducted from the beneficiary's Social Security payment. The division between hospital and physician service coverage is due to historical and political factors in the mid-1960s, and the Medicare program was based on practices and structures in the private sector at that time, particularly Blue Cross and Blue Shield (IOM, 1993).

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

Medicare has always paid for the evaluation of mental health problems, but it has strict limits on the level of coverage and on the specialty practitioners eligible for reimbursement (Lave and Goldman, 1990). Less than 3 percent of Medicare spending goes to mental health (Frank and McGuire, 1996), and this does not include the social support services and wraparound and enabling services such as employment counseling and child care that other public-sector programs support. However, expenses for mental health services have been rising faster than other Medicare expenses (Frank and McGuire, 1996).

The total costs of the Medicare program approached $185.6 million in 1995 (HCFA, 1995), and federal policymakers have turned to managed care as a means of controlling the increases in costs. As of December 1995, more than 10 percent of Medicare recipients (4 million of a total of 37.6 million recipients) were enrolled in managed care plans (HCFA, 1995) (see Table 4.2). During 1995, the number of managed care plans serving Medicare recipients grew at a rate of more than 25 percent (HCFA, 1995). Nationally, 74 percent of beneficiaries have a choice of one managed care plan, and 53 percent have a choice of two or more managed care plans. The majority of Medicare beneficiaries who are enrolled in managed care plans live in California, Florida, Oregon, New York, and Arizona (HCFA, 1995).

A Medicare version of HEDIS is under development by the Health Care Financing Administration (HCFA) and the Kaiser Family Foundation. The new system will adapt an existing reporting system that will minimize reporting burdens and also standardize the measurement of quality across plans. Beginning in 1997, managed care plans serving Medicare beneficiaries will be required by HCFA to submit data on the HEDIS measures that are relevant to Medicare.

SUBSTANCE ABUSE SERVICE SYSTEMS

Services for the treatment of alcoholism and drug abuse are provided in multiple settings: primary care and acute care facilities, mental health clinics, office-based practices by individual practitioners, and specialty substance abuse treatment programs (see Table 4.3). The National Drug and Alcohol Treatment Utilization Survey (NDATUS) (recently renamed the Uniform Facility Data Set [UFDS]) provides descriptive data on public and private specialty treatment programs. NDATUS began in 1976 as a census of publicly funded drug abuse treatment programs and expanded to include alcoholism treatment services in 1979 (SAMHSA, 1995a). Currently, all public and private programs licensed or approved to provide treatment for alcoholism and drug abuse are surveyed, including units in general hospitals, community mental health centers, and freestanding residential and outpatient addiction treatment services; private practitioners and group practices are generally not included in the census. The National Facility Register was updated and expanded for the 1995 version of UFDS. At present (August 1996), however, the most recent reports are based on data from the 1992

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

NDATUS and estimate that 944,880 men, women, and adolescents were in care in 11,316 treatment programs on September 30, 1992 (SAMHSA, 1995a).

TABLE 4.3 Types of Care in Substance Abuse Treatment

Type of Care

Description

Detoxification services

Detoxification services are designed to guard against medical emergencies that often accompany withdrawal. They frequently serve as the client 's introduction to the rest of the publicly funded treatment system.

Inpatient hospital detoxification

Inpatient hospital detoxification services are provided in a 24-hour, supervised medical (hospital) setting. Hospital programs are generally more expensive than traditional programs in a social setting, and research indicates such programs are not generally necessary for less severe cases. Therefore, these services are generally available to publicly funded clients only when they have very serious, life-threatening situations.

Freestanding, residential (nonhospital) detoxification

Inpatient social setting (nonhospital) detoxification services are provided in a 24-hour, supervised (nonhospital) setting. This type of service is used most frequently with publicly funded clients.

Outpatient detoxification

Detoxification services provided in a day (rather than 24-hour, supervised) setting. Infrequently used in the public setting; research indicates that this service may be both clinically effective and cost-effective for many clients. However, this type of service may be too risky for severely addicted patients.

Residential services

Residential services are provided in a 24-hour non-acute care setting. Each residential service setting may provide a variety of clinical services such as individual and group counseling.

Short-term residential services

Short-term services are typically for 30 days or less. Short-term services are usually provided to clients with moderate to severe addiction levels.

Long-term residential services

Long-term services are typically more than 30 days and may include recovery homes or transitional living arrangements such as halfway houses. Long-term services are generally geared to men but are also used for special populations, such as pregnant women and youth, who are considered to be more difficult to treat.

Outpatient/ambulatory services (non-intensive)

Outpatient services generally include individual, family, and group counseling. Pharmacological therapies, such a methadone treatment, may be used as an adjunct to outpatient services.

Intensive outpatient services

Services last 2 or more hours per day for three or more days per week.

Methadone services

Prescribed pharmacological services combined with traditional outpatient counseling services. Methadone clients are generally enrolled in programs for considerable (multiple-year) lengths of stay.

Outreach services

The goal of outreach programs is to get clients into treatment. Most programs are aimed at special identified populations such as court-adjudicated clients or clients with small children.

Prevention services

Prevention services are aimed at the general population. Some programs are targeted at high-risk groups, such as low-income youth or school dropouts. Programs include a broad range or services such as education, self-esteem enhancement, and the provision of alternative activities.

Wraparound or enabling

Wraparound or enabling services are loosely defined as ancillary services that make it easier for the client to access and stay in treatment or to obtain better outcomes upon discharge from treatment. Examples may include housing assistance, child care, transportation, and employment counseling. In many cases the services are provided within the treatment agency.

EAPs

EAPs attempt to solve alcohol- and other drug-related problems in the workplace. EAPs contain five elements: (1) detection of decrements in job performance, (2) constructive confrontation, (3)referral process, (4) ongoing contact with treatment facility, and (5) intolerance to drug abuse in the workplace.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

NDATUS and estimate that 944,880 men, women, and adolescents were in care in 11,316 treatment programs on September 30, 1992 (SAMHSA, 1995a).

The 9,307 facilities that responded to the 1992 survey included 1,650 (17.7 percent) privately funded programs and 332 (3.6 percent) programs within various federal entities (Bureau of Prisons = 73, DOD = 59, VA = 128, and Indian Health Service = 108) (SAMHSA, 1995a). The majority of the respondents were community-based agencies that receive funding from federal, state, or local government (n = 7,325, 78.7 percent). An additional 2,009 agencies were reported as nonrespondents and may include a disproportionate share of private agencies. Nonetheless, it is clear that publicly funded service practitioners predominate in the specialty system for the treatment of alcohol and drug dependence.

More than half of the facilities (56.2 percent) were either freestanding outpatient programs (n = 4,923; 43.5 percent of the respondents) or community-based mental health centers (n = 1,440; 12.7 percent). These two types of outpatient services reported treating 69.2 percent of the patients in care (freestanding = 506,774; community mental health center 146,941). About 15 percent of the respondents were general hospitals (n = 1,181) or specialized hospitals (n = 547), and together these served 118,598 patients (12.5 percent). Residential programs

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

(halfway houses, recovery homes, and residential treatment in therapeutic communities) included 2,474 facilities (21.9 percent) and provided care to 87,494 individuals (9.2 percent). The remainder of the facilities were either correctional programs (n = 312) with 30,658 clients or unknown practitioner types (n = 439) serving 54,413 individuals. Most of the facilities were small, independent agencies; nationally, the mean caseload per facility was 83.5 clients.

The extensiveness of the treatment systems varies substantially from state to state; more than 500 separate services in each of 4 states with large urban centers responded (California = 1,186; New York = 1,001; Michigan = 583; and Florida = 560) and less than 50 programs in each of 13 smaller states responded (Vermont = 17; Idaho = 25; Montana = 29; Alaska = 34; New Hampshire = 40; West Virginia = 40; Wyoming = 40; North Dakota = 41; South Dakota = 43; Delaware = 44; Alabama = 47; Arkansas = 48; and Hawaii = 48). A calculation of the number of clients per capita suggested that nationwide there were 432 clients per 100,000 population; nine states and the District of Columbia had rates that exceeded 600 clients per 100,000 population (Washington, Oregon, California, Alaska, Colorado, New Mexico, Washington, D.C., Maryland, New York, and Rhode Island), and the rate was less than 200 per 100,000 population in nine states (Minnesota, Iowa, Arkansas, Mississippi, Tennessee, Alabama, Georgia, Hawaii, and New Hampshire).

The 1992 NDATUS (SAMHSA, 1995a) analysis suggested that 29 percent of the individuals in care were women. One in 10 were 20 years of age or younger, and less than 1 percent were 65 years of age or older; most (75 percent) were between the ages of 21 and 44 years. Analysis of racial and ethnic characteristics found that 60 percent were white, 22 percent were African American, and 15 percent were Hispanic. Both alcohol and drug dependence was reported by 38 percent of the clients in care, whereas 37 percent were dependent only on alcohol and 25 percent were dependent only on drugs. Private practitioners were more likely to treat white men who were abusing alcohol.

More detail on the men and women treated in publicly funded alcohol and drug abuse programs is provided in the analysis of the Treatment Episode Data Set (TEDS). The Substance Abuse and Mental Health Services Administration (SAMHSA) in collaboration with the state authorities for substance abuse collects and maintains a database (TEDS) on the admissions characteristics of individuals admitted to publicly funded substance abuse treatment services. TEDS provides information on the primary drug of abuse, client characteristics (gender, race or ethnicity, education, and employment status), the presence of health insurance, and the type of treatment service. (Many of the states collect more detailed information, but the national data set is limited to key variables.)

The most recent report from SAMHSA examines admissions during federal fiscal year 1993 (October 1992 through September 1993) and compares current data with data from previous years to speculate about trends in client admissions (SAMHSA, 1995b). The SAMHSA (1995b) report counts 1.4 million admis-

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

sions to programs in 45 states plus Puerto Rico and the District of Columbia. The admissions included women (28 percent), adolescents (19 years of age and younger, 8 percent), adults (20 to 29 years of age, 30 percent; 30 to 39 years of age, 39 percent; and 40 to 49 years of age, 16 percent), older individuals (50 years of age and older, 6 percent), whites (59 percent), African Americans (28 percent), Hispanics (11 percent), Native Americans (2 percent), and Asian Americans (0.6 percent). Two-thirds (67 percent) were unemployed at admission, 15 percent were homeless, and 63 percent had completed high school. One third (33 percent) of the admissions to publicly funded services were involved with the criminal justice system, and only 1.5 percent were referred by an EAP. Most of the clients (61 percent) were admitted to outpatient services, but 23 percent were in detoxification programs and 16 percent were in short-term (9 percent) or long-term (8 percent) residential services. Alcohol was the primary drug of abuse (58 percent), but cocaine (19 percent) and heroin use were common (13 percent).

Client characteristics vary by drug of choice (SAMHSA, 1995b). Nearly three of four (73 percent) individuals admitted to care for only alcohol abuse were white; 14 percent were African American and 9 percent were Hispanic. Among individuals seeking treatment for heroin abuse, 43 percent were white and more than one in four were African American (27 percent) or Hispanic (28 percent). Clients who reported that crack cocaine was their primary drug of abuse were most likely to be African American (70 percent); one in four (24 percent) were white and about 5 percent were Hispanic. Stimulant (amphetamine) users, on the other hand, were predominantly white (82 percent) or Hispanic (9 percent); only 4 percent were African American. Public treatment programs therefore need to have much sensitivity to racial and cultural patterns of abuse and must be responsive to different cultural needs.

Funding for publicly supported substance abuse treatment services comes from state, local, and federal appropriations. Analysis of data from the 1994 State Alcohol and Drug Abuse Profile (NASADAD, 1996) suggests that for fiscal year 1994 total public funding for substance abuse prevention and treatment services reached nearly $4 billion. State appropriations made up 38 percent ($1.5 billion), the federal Substance Abuse Prevention and Treatment Block Grant added 28 percent ($1.1 billion), other federal funds provided an additional 10 percent ($378 million), local county and municipal governments contributed 6 percent of the total funds ($247 million), and other sources accounted for 18 percent ($723 million) (NASADAD, 1996). Between 1989 and 1994 state funding increased 24 percent, whereas funding from the federal block grant increased 139 percent. In total, state appropriations, however, were still in excess of the funding level from the federal block grant.

MENTAL HEALTH TREATMENT

Mental health services are provided in multiple settings: primary care and

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

acute care facilities, outpatient clinics, office-based practices by individual practitioners and by groups of primary care and specialty practitioners, and nonmedical settings such as the workplace, schools and universities, and community-based settings. Thus, the continuum of care ranges from the most restrictive settings (inpatient hospitalization and residential treatment) to the least restrictive settings (community-based programs and outpatient counseling). Typically, substance abuse treatment is considered a part of mental health treatment because of the similarities in treatment and financing. In this section, the focus is on the treatment of mental health problems.

We have a pluralistic system, and we have great diversity in our service delivery system, which I think is one of its strengths.

Judith Hines

Council on Accreditation of Services for Families and Children

Public Workshop, May 17, 1996, Irvine, CA

Traditionally, states fund a large proportion of mental health treatment, dominated by inpatient hospitalization. States historically have operated with categorical budgets, with public funds earmarked for specially defined populations, such as runaways or other homeless individuals. Over the years, state mental health agencies have begun to contract with an array of practitioners, including community mental health centers and non-profit community based service agencies (Essock and Goldman, 1995). As discussed in Chapter 3, the public system delivers care for individuals who are uninsured and underinsured and serves a safety net function.

Table 4.4 and Table 4.5 display the range of mental health treatment settings, including those in both the public and private sectors.

Because community-based services play an integral part in the delivery system, the next section describes them in more detail.

WRAPAROUND SERVICES

In the public sector, federal and state policies have promoted the development of a coordinated continuum of care. Wraparound or “enabling ” services such as transportation to treatment, child care, employment services, legal assistance, and other services have traditionally been an integral part of publicly funded treatment systems for two primary reasons (Institute for Health Policy, 1995). First, the historical evolution of treatment systems for alcoholism and drug dependence has taken place largely outside of medical systems and medical models of care,

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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TABLE 4.4 Mental Health Treatment Settings

Setting

Description

General Hospital

Emergency rooms

Evaluation and referral services, most often to psychiatry department. Staffed by nurses, residents, and attending physicians. Paid for by private or public insurance or is uncompensated.

Inpatient psychiatry

Short-term, acute care. Evaluation and referral to long-term or outpatient care. Staffed by psychiatric nurses, psychiatric residents, and psychiatrists. Paid for by private and public insurance. Referrals from emergency room staff, medical staff, private practitioners, and outpatient clinics.

Outpatient psychiatry

Ambulatory care provided by psychiatrists, social workers, psychologists, and psychiatric nurses. Long- and short-term care paid for by private and public insurance.

Specialty Care

 

Private psychiatric hospital

Short-term acute care; may specialize in chemical dependency, rehabilitation, children and adolescents. Referrals to outpatient and residential treatment.

State psychiatric hospital

Diagnosis and stabilization for seriously and chronically mentally ill individuals who are experiencing highly symptomatic illnesses. Paid for primarily with state funds.

Community mental health center

Short-term and long-term care for the full range of psychiatric disorders, including rehabilitation, residential treatment, and vocational supports.

Day hospital

High-intensity outpatient treatment for individuals who are symptomatic but who do not need 24-hour inpatient care; may include intensified medication management, treatment, and vocational rehabilitation.

Private practice

Psychiatry, psychology, social work. Solo private practice, preferred provider organization network, or other office-based arrangement.

Nursing homes

Long-term specialty care for individuals with severe disorders and organic mental illness

Community-Based, Nonmedical

 

Crisis center

Shelters for those affected by domestic violence, runaways, and individuals who are homeless or need rape counseling. Often staffed by volunteers in donated space, with volunteer professional staff (physicians, nurses, social workers, psychologists, counselors). Funded primarily by donations from charitable organizations and grants. Provide referrals.

Family/social services agencies

Child welfare, foster care, and family reunification programs and case management. Typically staffed by social workers. Include public agencies and private not-for-profit groups.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Community-Based, Nonmedical

Schools and universities

Elementary and high school clinics staffed by nurses. Campus counselors include social workers, psychologists, and psychiatrists. Private insurance or free to students, sometimes to families.

Religious organizations

Counseling by ministers, rabbis, and other clerical personnel

Peer counseling

Social support groups sponsored by hospitals, human services agencies, practitioners, and other volunteers.

Halfway house, transitional living

In combination with outpatient psychotherapy, can help avoid relapse.

relying instead on social services agencies, self-help recovery groups, community-based practitioners, and other nonmedical programs. Second, federal and state policies have supported and encouraged the development of comprehensive program models that facilitated entry to care and support for continued care. These services were identified as “enabling ” services in the health plan proposed by President Bill Clinton (White House Domestic Policy Council, 1993).

A portion of the state-managed substance abuse treatment services is funded through the Substance Abuse Prevention and Treatment Block Grant administered by SAMHSA. The block grant and other discretionary funding streams

TABLE 4.5 Comparison of Public and Private Sectors of Care in Mental Health

Characteristics

Public-Sector

Mental Health Care

Private-Sector

Mental Health Care

Population served

Mostly uninsured, emphasis on the seriously mentally ill

Those with coverage

Funding of care

State general funds, Medicaid and Medicare revenues, local and other funds

Insurance premiums

Locus of treatment responsibility

Local authority (e.g., county government), community mental health center

Insurance plan and/or provider

Predominant services

Case management, medications, housing support, rehabilitation, crisis intervention, and hospitalization

Outpatient therapy, medications, and hospitalization

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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emphasize comprehensive program models. Moreover, state dollars (added to these systems through general revenue funds) often permit case management and other supportive services. Most states also use Medicaid funds, although the proportion of Medicaid funds supporting alcohol and drug abuse treatment services is relatively small compared with that from other funding sources.

Diagnosis is really an inadequate predictor of the need for services. We need to look both at the functional level at the client, as well as the support system in the environment.

Rita Vandivort

National Association of Social Workers

Public Workshop, April 18, 1996, Washington, DC

If the goal of treatment is long-term recovery from alcohol and other drug abuse, as well as from severe mental illness, wraparound services are often needed to sustain the progress made through medical and psychosocial treatment. Table 4.6 displays many of the wraparound and enabling services used to help individuals with substance abuse and mental health problems. In the movement to managed care, treatment services may be limited to the most essential medical elements; for example, wraparound services that have been developed to support recovery may be eliminated because they are considered “not medically necessary.” It is important to recognize that recovery from addiction is not simply a medical issue: complex behavioral factors are intertwined with the medical aspects. Chapter 5, Access, discusses these issues further.

We think we can bring a more comprehensive focus to the ideas of what is necessary—looking beyond narrow definitions of medical necessity to areas of human necessity, which could include having basic income, having help in getting housing, and ongoing support services.

Elizabeth Edgar

National Alliance for the Mentally III

Public Workshop, April 18, 1996, Washington, DC

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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TABLE 4.6 “Wraparound” and “Enabling” Services

Service

Definition

Link to Treatment and Recovery

Cash assistance

Provides income support. Public programs include Supplemental Security Income disability payments, general assistance (welfare), and food stamps.

Without support, most publicly funded clients were unable to complete a treatment regimen. Basic needs, food and shelter, must be met before the client can devote him- or herself to treatment and recovery.

Child care

Provides child care services at no or low cost while parents (generally mothers) attend treatment.

Lack of child care is a barrier to treatment for most women with children.

Domestic violence services

Provides assessment and counseling to clients who have experienced domestic violence or sexual abuse.

The rates of domestic violence and sexual abuse among substance abusers —particularly women—are very high. In many cases, a women's admission to treatment is precipitated by a life-threatening event or crisis.

Education

Provides information as well as direct assistance with enrollment in college/community college or completion of high school/ GED programs.

Education contributes to a successful recovery. Education also provides the skills necessary to find work.

Employment counseling

Assists clients in assessing their strengths and weaknesses, learning new job skills, and finding employment.

Without employment, the client is more likely to have trouble living independently or to suffer a relapse.

HIV and TB screening and referral

Provides infectious disease screening, testing, and referral for clients entering and participating in treatment programs.

Reduces risks of infection.

Housing

Assists clients in finding safe and affordable drug-free housing, including recovery homes and halfway houses.

Supported housing enables the client to move out of residential treatment more quickly. A stable living environment is associated with successful treatment and recovery.

Legal assistance

Clients who experience legal problems often receive case management services. Others may be referred to community legal aid programs.

Many substance-abusing, publicly funded clients are referred to treatment in lieu of prosecution or incarceration. Case managers track the client's progress and can assist with Supplemental Security Income disability payments. Seriously mentally ill clients may need legal assistance with civil commitment or other issues.

Parent skills training

Provides parent education and training to help parents function in their family roles during the treatment process.

Mental illnessss and substance abuse disrupts families, which can hinder treatment and recovery.

Transportation

Provides direct transportation information or financial help with public transportation.

Lack of transportation is a barrier to participation in treatment; transportation helps clients continue treatment when they may not have otherwise been able to do so.

NOTE: Other important services that are not wraparound or enabling services include physical health care and vocational rehabilitation. HIV, human immunodeficiency virus; TB, tuberculosis.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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THE MANAGED BEHAVIORAL HEALTH CARE INDUSTRY

Background

The organization and financing of mental health and substance abuse treatment have changed dramatically since 1980. The costs of mental health and substance abuse treatment increased faster than both the general rate of inflation and the increases in the costs of the rest of health care in the mid-1980s (about 15 percent a year). By 1991, behavioral health care costs represented 10 to 25 percent of all health care expenditures and became a prime target for cost-containment strategies (Sharfstein and Stoline, 1992; Shore and Beigel, 1996; Sullivan and Miller, 1991).

Psychiatry was excluded from the diagnosis related grouping system in 1983 when it was not clear how to compare mental health services in an equitable way, resulting in a rapid expansion in the number of psychiatric hospitals and the number of inpatient psychiatric beds (Sullivan and Miller, 1991). Between 1980 and 1986 the number of admissions to private psychiatric hospitals increased by 400 percent for adolescents, the average length of stay increased, and per diem costs rose more rapidly than costs in the general medical sector (Jellinek and Newcombe, 1993). Approximately one-third of the increase covered substance abuse treatment (Sullivan and Miller, 1991). Thus, treatment for adolescents and substance abusers was the main component of the cost increases; however, these hospitalizations were not always clinically justified and the results for patients were mixed (England and Goff, 1993).

One consequence of these developments was an increase in for-profit companies contracting to manage behavioral health care benefits. As of January 1995, the combined annual revenue of these companies was estimated to be $2.1 billion; more than half of the amount came from contracts in which the companies were at financial risk (Iglehart, 1996; Oss, 1995). A 1995 survey found that 21.7 million people were enrolled in capitated programs in which behavioral health companies were paid an average of $60 per individual per year (Oss, 1995).

Although managed behavioral health care companies have demonstrated cost savings in the area of behavioral health (Iglehart, 1996), the effects on quality of care are less clear. The trend toward consolidation, mergers, and integrated systems means that there is increasing pressure within the industry to standardize treatment and information systems (CBGP, 1995). There is also more pressure from consumers and other purchasers to demonstrate that appropriate-quality care is being provided efficiently.

Performance Measurement

Two main organizational forces develop standards and measure quality in the behavioral health care industry. One is the American Managed Behavioral

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Healthcare Association (AMBHA), the industry membership organization founded in 1995. AMBHA member organizations currently manage mental health and substance abuse care for more than 80 million Americans (AMBHA, 1995). AMBHA works closely with the National Association of State Mental Health Program Directors in developing joint health care policy statements and other collaborative efforts (e.g., AMBHA and NASMHPD, 1995).

In 1995, AMBHA released its first report card, Performance-Based Measures for Managed Behavioral Healthcare Programs (PERMS 1.0). The measures are chosen to be “meaningful, measurable, and manageable ” and are classified into three domains: access to care, consumer satisfaction, and quality of care. Measures are based on available data systems, primarily based on existing administrative and reporting data bases. AMBHA has begun field testing of PERMS, and all AMBHA members have agreed to participate (Bartlett, 1996). In Chapter 6, PERMS measures are compared with other current performance measures for behavioral health care.

The Institute for Behavioral Healthcare (IBH) is also influential in the industry, publishing a journal, conducting conferences, and sponsoring other professional development activities in managed behavioral health care. In 1996, IBH released the results of a survey of members of its Leadership Council, a coalition of more than 170 behavioral health care organizations throughout the behavioral health care industry. The survey was completed by 47 percent of these organizations, with representation from four segments of the industry: (1) mental health facilities and integrated delivery systems, (2) community mental health centers and social and rehabilitation service agencies, (3) behavioral group practices, and (4) managed care organizations. The purpose of the survey was to evaluate the current use of a variety of performance indicators and their appropriateness and validity for measuring performance and the feasibility of using these indicators to measure performance (IBH, 1996).

The different segments of the industry, however, varied significantly in types of indicators used to measure access for their clients. For example, the availability of telephone access is frequently used to indicate access to managed care companies but is not used by other organizations that do not possess electronic telephone monitoring systems. The most frequently used indicators of outcomes were symptom reduction, improved functioning, and readmissions to treatment.

Efforts to standardize services and measure performance in managed behavioral health care organizations seem to be a priority for the industry. However, these efforts are in the preliminary stages, and it still is difficult for consumers, employers, and other purchasers of care to compare value and quality across plans.

WORKPLACE SERVICES

The workplace is a primary point of access for health care. An employee 's behavior, style, and habits become well known and recognized by coworkers. Changes

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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are frequently recognized in the workplace through declines in the quality of or other changes in work performance. Many times these changes are noticed in the workplace even before they are recognized in the home. Attention to workplace performance can be one of the best means of identifying behavioral problems. Then intervention can occur and the individual can be provided with the help and assistance he or she needs to resolve behavioral health problems. Through prevention, wellness, and early intervention efforts, attention to performance at the workplace facilitates access to health care, contributes to improved health status, and contains costs.

The employee assistance programming field was developed for and has evolved services to assist employers with identifying and resolving behavioral problems and to provide them with a means of intervention (Roman, 1988). Historically, EAP staff worked almost exclusively with individual workers. Organizations now provide assistance with issues related to the productivity, safety, health, and well-being of the entire workforce. This section discusses EAPs, consultation with management, disability management, integrated services, wellness and prevention efforts, training and education, regulatory compliance, demand management, and services for those with special needs, such as those affected by violence and downsizing.

Employee Assistance Programs

An EAP is a worksite-based program designed to assist in the identification and resolution of productivity problems associated with employees impaired by personal concerns including, but not limited to, health, marital, family, financial, alcohol, drug, legal, emotional, stress, or other personal concerns that may adversely affect employee job performance. An EAP is designed to identify problems at an early stage, motivate an employee to seek help, and provide the resources needed to assess and resolve the problem. The program is both a supervisory tool and an employee benefit. An individual can access the service through a referral made by a manager, supervisor, or labor representative, or through self-referral.

EAPs also assist family members. They maintain high levels of confidentiality, focus on early intervention, and are available to employees and family members 24 hours a day. Well-designed EAPs have produced significant outcomes for employers and those that use the services. EAPs are usually evaluated on the basis of the number of employees who use the services as well as the types of problems addressed and the outcomes achieved. Typically, outcomes are defined as improvements in identified problems, access and experience with the resources that were needed, and improved levels of functioning in the individuals who were serviced. Studies have shown that employers, on average, receive a $3 return for every $1 invested in the service (Winslow, 1989). Anecdotal evidence suggests that indi-

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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viduals who use these services realize up to an 80 percent resolution of their presenting problems (Burke, 1996).

The specific core activities of EAPs include the following:

  • expert consultation and training to appropriate persons in the identification and resolution of job performance issues related to an employee' s personal concerns;

  • confidential, appropriate, and timely problem-assessment services;

  • referrals for appropriate diagnosis, treatment, and assistance;

  • the formation of linkages between workplace- and community-based resources that provide such services; and

  • follow-up services for employees who use those services.

Enhanced program services include wellness and health promotion, critical incident (crisis) services, disability management, behavioral health case management, and organizational change management.

Typical program models include the following:

  1. internal: worksite based and staffed by employees of the organization, with or without professional credentialing;

  2. external: may or may not be worksite based and is staffed by outside (outsourced) practitioner or vendor;

  3. mixed: utilizes a combination of both internal and external models.

EAPs have a multitiered relationship with the managed behavioral health care system. They assist with prevention through health promotion and risk reduction activities. They promote the early identification of problems through easily accessed assessment and referral services. They facilitate effective treatment by assisting with the coordination of care, treatment, and workplace support. They assist in controlling costs by addressing gaps or duplication in services, helping deal with barriers to treatment compliance, facilitating return-to-work plans, providing support, advocacy, and follow-up for clients, and serving as liaisons between the treatment community and the workplace.

Management Consultation and Regulatory Compliance

Federal regulations influence the management of employees with behavioral problems, and behavioral health management consultants often assist in the development and implementation of plans for regulatory compliance. The regulations with the most direct impact on the workplace are the Americans with Disabilities Act, the U.S. Department of Transportation, DOD, and Nuclear Regulatory Commission regulations on drug-free workplaces, and the Family Medical Leave Act.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Each set of regulations gives the clearly defined roles and responsibilities related to managing specific behavioral problems. An employer is obligated to establish a plan for implementing each set of regulations and is monitored in its compliance with these regulations. These regulations force employers to pay attention to many problems that affect employees and also increase the likelihood that employees who choose to comply will be given access to well-designed treatment plans.

Workplaces have the potential for violent situations, critical incidents such as a an industrial accident, the sudden death of an employee, or a natural disaster, and increased stress due to change, downsizing, or plant closings. Behavioral consultants with specialized training are becoming more available to managers and supervisors to develop programs that can be used to address these issues. Consultant services include case-by-case consultations, policy design, definition of action plans, proactive planning, and organizational change management (e.g., the orchestration of awareness efforts and other types of training for supervisors, managers, and labor representatives).

Behavioral Health Disability Management

Management of a behavioral disability is an area that has not received much attention. Disability management involves the management of an employer's workers' compensation plan (occupational disability) along with its short-term and long-term disability benefit (nonoccupational disability). Because only a limited number of states allow a behavioral health claim through workers' compensation, the areas that are generally managed are nonoccupational disabilities.

Disability management involves a variety of service components that focus on getting an employee the most appropriate care necessary to enable the employee to return to the workplace in a timely fashion. A behavioral health disability management service is composed of a plan design, specially trained disability case managers, assessment instruments, a specialized practitioner network, and return-to-work protocols.

Behavioral health disability management services are delivered through interactions with the employee, the employer, and the practitioner. Because of the nature of the service provided, the behavioral health disability management service is backed by an appeals process, physician advisers, and an independent medical evaluator network. To minimize the extent of exposure from disability claims, employers implement preventive measures and link the disability program to an EAP.

Integrated Services

Many behavioral health care services overlap and begin to duplicate existing or potentially available services (e.g., the existence of a behavioral managed

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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health care service and an EAP). The existence of these stand-alone services results in the potential for duplication in accessing a practitioner and in the delivery of care. Significant movement, however, has been made toward integrating managed care with EAPs to allow for the blending of the strengths of each service, thus enhancing the overall service delivered in the workplace.

Another motivator for the integration of the two service components is the financial efficiencies that come from managing one rather than two systems. To create financial efficiencies, employers are looking for opportunities to link services and for a “one-stop shopping ” opportunity. In an integrated system, the managed care entity focuses on the user of the service and the practitioner. The EAP focuses on the employee and the employer. The linkage of the employee, the employer, and the practitioner enhances the opportunity for the successful treatment of an individual. The EAP can become part of the continuum of care and can provide problem resolution or short-term counseling. Often, the EAP is positioned as the entry point (gateway) to the behavioral health care benefit by providing the assessment and referral to the practitioner network, with ongoing case management provided by the managed care entity.

As purchasers of health care, employers are demanding higher levels of efficiency and cost-effectiveness. These expectations may increase the integration of behavioral health, primary care, and EAP services.

Health Promotion, Wellness, and Prevention

Worksite health promotion is an organized effort supported by an employer to improve employee health, fitness, and well-being. Programs can include health education, behavioral change, occupational health (e.g., workers' compensation and ergonomic training and evaluation), fitness, and recreation services. Most worksites offer health promotion programs because of the possibility of reduced employee health risks, reduced absenteeism, improved employee morale, and controlled costs for health care. At least one-third of employers offer specific health promotion programs, such as smoking cessation, weight control, cholesterol screening, stress management, and exercise programs (EBRI, 1991; Foster Higgins, Inc., 1994).

An employee's use of prevention programs can reduce his or her risk of developing behavioral health problems. Computerized health risk appraisals might be used to identify areas in which an employee might benefit and be interested. Behavioral change programs include programs in such areas as stress management, depression recognition, relationships counseling, assertiveness training, communications skills, and other areas. Programs can be managed through the EAP, with programs held on-site or outsourced to local consultants. Programs also may be associated with health maintenance organizations (HMOs) or managed care plans; for example, health clubs may offer reduced membership rates to enrollees in particular health plans.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Employers implement health promotion programs to enhance employees ' quality of life and well-being. In turn, employers can realize savings in corporate health care costs. Some employers reward their employees for healthy behavior by offering discounted health care premiums or rebates or through credits or coupons (IOM, 1993). Employers and health care delivery systems must continue to innovate in areas of prevention and wellness to reduce the prevalence of chronic illness and minimize the financial impacts of these illnesses.

Demand Management

Increasingly, demand management programs are used to educate consumers and prevent serious illness. Demand management provides an array of services including a variety of training and educational programs, ready access to information through toll-free lines that connect an individual to health care professionals, and programs of early detection and self-care. Demand management empowers consumers to be better users of the health care system and to monitor and manage their own health.

Training and Education

Management and labor have valued training and education as a means of providing employees with information that not only assists in self-improvement but that also assists an individual in being more productive in the workplace. Training and education have a proven value and are used frequently. Employers are asking behavioral health care specialists to assist in better informing employees and their family members on areas such as stress, parenting, relationship building, alcohol and drug use, AIDS, caring for the elderly, and communications skills. Behavioral health care specialists conduct training programs so that employees not only gain information but also, many times, use this information as a motivator for accessing the health care delivery system.

Summary of Workplace Issues

The workplace provides one of the best means of accessing health care in the United States. To take full advantage of this potential, it is important that both the employer and the health care industry recognize the power of the workplace. The workplace provides a means of informing and educating the consumer, it provides the financial means for many to access the necessary care, and it serves as a means of early intervention for problems that hold the potential to develop into chronic and costly illnesses.

The field of behavioral health care must recognize the gains that have been made through workplace services and build on that capability. Through the workplace, the potential to gain access to health care will be maximized for the benefit of

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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employees and their family members, employers, and the health care delivery system.

U.S. DEPARTMENT OF DEFENSE AND U.S. DEPARTMENT OF VETERANS AFFAIRS

Background

The federal government has long provided acute and rehabilitative medical services, including mental health care services, for its military personnel. Before World War II, mental health services were limited for active-duty members and were not provided to retirees and their families. With the growth of federally-funded programs during the Depression and World War II, the federal role in providing assistance to state and local governments and its citizens was expanded. The departments of the Navy, Army, and Air Force sustained their medical departments following World War II by building several large tertiary care facilities and obtaining funding for health care programs and personnel. With a large number of injured veterans returning from World War II and the Korean War, the Office of Veterans Affairs (now the Department of Veterans Affairs [VA]) similarly expanded from a modest program providing disability compensation and rehabilitation services to a national system of hospitals and rehabilitation facilities during the 1950s.

With the concurrent growth of other federal programs, both the VA and DOD expanded the scope of their services to include acute and chronic mental health and substance abuse conditions. They aimed to promote professionalism and quality of care through affiliations with medical schools, instituted accredited professional training programs, and made commitments to medical research. With a steady stream of physicians and dentists obligated to military service under the 1933 Selective Services Act, the military was able to medically staff its global system of hospitals and clinics.

Surveys of military personnel leaving the services for civilian work in the 1950s consistently revealed that a major reason for resigning was the limited availability of specialized military or civilian medical services for the families of service members. To bridge this gap, the U.S. Congress enacted in 1964 the Military Medicare Program, later called the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), to provide health benefits and reimbursements for military family members seeking civilian health care, as well as for retirees and their families. This program was expanded to cover certain health care benefits for disabled veterans under a related program, the Civilian Health and Medical Program of the Veterans Administration (CHAMPVA).

With these new programs in place and a new war in Vietnam that would require even more resources for DOD and VA, the third generation of military health care was under way. With these direct and compensated care systems pro-

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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viding increasing benefits, each program grew substantially in funding and coverage during the next 30 years, and they now cover approximately 20 million eligible citizens.

Mental Health and Substance Abuse Programs

To meet its peacetime and war-related missions, the military provides mental health and substance abuse services to a heterogeneous population that has largely been representative of younger adults in the United States. Although the recruiting and early training processes allow some screening out of individuals who would have difficulty functioning in a military environment because of a mental disorder, many individuals require treatment as the result of biological factors, common life stresses, and the unique and sometimes extraordinary traumas associated with the dangers of military operations.

The families of military personnel are subjected to frequent moves, separations, and threats to the life of the parent or spouse who is a service member. The special needs of military families has resulted in historically high CHAMPUS expenditures for mental health care for family members of active duty and retired personnel. Although some have received “space-available” care by military mental health professionals, the very nature of military family life and the existence of different systems of care (DOD direct care and CHAMPUS), as well as civilian care for spouses with private insurance, complicates the coordination of treatment. An unknown number of these individuals receive care through Medicaid, Medicare, and local charitable and uncompensated sources. Epidemiological studies of this population are incomplete, preventing any meaningful conclusions about the longer-term social impact or health outcomes resulting from this uneven and uncoordinated approach to care.

Special Risk Populations in the Military
Children and Adolescents

Although the Army, Navy, and Air Force have a substantial number of family physicians and pediatricians providing primary care for children, they provide a limited amount of specialized mental health services for children and adolescents. A small number of social workers, especially in the Army and Air Force, provide a core of therapeutic services, especially in remote settings.

Children with special psychiatric and developmental needs are referred to U.S. civilian communities where CHAMPUS-supported residential treatment, special education, and other needed services can be obtained for these “exceptional” family members. When families have children with such needs, they frequently find themselves considering several options: ending their military affiliation to settle in a community that can provide long-term program assistance,

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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accepting the periodic long absences of the service member spouse or parent who can only receive a time-limited special assignment, or accepting an assignment to an area where special services might not be available for the child. The reluctance of many civilian communities to extend public services to military children and the limited military resources available to the family makes this group particularly high risk.

Adults With Chronic Relapsing Conditions

When a service member manifests a chronic relapsing mental health or substance abuse problem, he or she is provided a medical discharge and referred to the VA for follow-up. It is unclear how many drop out of VA care over time because of choice, which may or may not be affected by their perception of need. Many military occupations do not readily convert to civilian work, which creates a barrier to returning to a stable civilian setting. When a spouse is impaired, the service member's absence means a loss of day-to-day support. Although statistics are not available, anecdotal evidence indicates that many of these families dissolve. Ultimately, local communities inherit the responsibility for caring for the single-parent family, which frequently is without health insurance or other economic resources.

Older Adults

Depending on service availability, preferences, and financial abilities, retired military personnel may receive treatment in a military, VA or civilian program, both before and after age 65. Their family members, who are not eligible for care in the VA, may receive some limited care in a military facility, but they generally must count on CHAMPUS, private insurance, or, when eligible, Medicare to support their treatment needs. This multiplicity of sources, which may be variously elected during the course of an illness or even an episode of illness, can make it difficult to coordinate care.

Diversity

The culture of the military population reflects the diversity of cultures of the U.S. population and the cultures of citizens from other countries married to service members. Ethnic and cultural minorities find many opportunities for educational, occupational, and economic advancement in the military, and many consider military work and community life more egalitarian than life in their own communities of origin. Despite the services' successes in equal opportunity, however, cultural factors can result in unique stresses and problems in diagnosis and treatment, particularly when there are language barriers and different cultural approaches for treatment.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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A System In Transformation

Recognizing that there are many unique psychological challenges for military personnel and their families, DOD and VA have looked carefully at alternatives to the traditional costly and disconnected systems of care that they provide. The economic forces that have caused such significant restructuring of the private health care financing and delivery systems have also had an effect on public health care budgets, resulting in less money to fund staff and facilities and to provide reimbursements for fee-for-service care under CHAMPUS and CHAMPVA. Like Medicare and Medicaid, DOD and VA have looked at managed care alternatives in recent years. Given the leadership and political sensitivities of the DOD mission, it has been important that federal forays into utilization management and managed care be structured with attention to quality of care and service.

A first major initiative in managing DOD mental health care services quality occurred in 1974, when the U.S. Congress investigated problems associated with residential treatment of children and adolescents. Over the ensuing 7 years, CHAMPUS collaborated with a number of organizations (e.g., the American Psychiatric Association, the American Psychological Association, and the National Institute of Mental Health) to develop residential treatment center certification standards, accreditation, and admission and treatment criteria. These were followed by targeted programs in San Diego, California, and the tidewater area of Virginia, that structured care for persons with depressive disorders and schizophrenia.

In 1981, CHAMPUS launched a national peer review program with the American Psychiatric Association and the American Psychological Association to better account for quality and costs in inpatient and outpatient settings through structured record reviews. This program migrated to commercial insurers and eventually promoted the development of a number of private managed behavioral health care companies during the mid-to-late 1980s. During this same period, DOD established contracts for a targeted mental health demonstration project in the Tidewater area and for a comprehensive managed care program in California and Hawaii, the CHAMPUS Reform Initiative.

These and a number of other pilot programs and demonstrations, such as a joint DOD and state of North Carolina child mental health project at Ft. Bragg, provided a mounting case for structured managed care arrangements to meet DOD goals of reducing avoidable costs and accounting for quality of care. During this same period, VA was considering various complementary managed care approaches, but it was constrained by political concerns about reducing veterans' access to centralized care in VA medical centers.

With the experience of several years of experimenting with options and considering cost and quality issues in contracting with private managed care firms, DOD has now embarked on a major initiative, termed “TriCare.” DOD is using a combination of pooling of Army, Navy, and Air Force personnel and facilities with local targeted contracting to provide regional systems of care. Consumers

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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(beneficiaries) are given the option of choosing direct military care when available, a point-of-service option, and where available, HMO and preferred provider organization options, with variable cost-sharing for beneficiaries of different status (i.e., active duty versus retired). Copayments are comparable for primary care and behavioral health care.

DOD will be accounting for quality in these systems through a combination of licensing, accreditation, certification, reporting and auditing, and grievance and appeal requirements. Since this initiative is so new, it is unclear whether it will solve DOD's problems, create new ones, or begin to address the problems in disconnected care that has plagued the military health care system for so long. In the mass of uncertainty is how mental health and substance abuse services for both active duty personnel and active and retired military families will be affected.

CARE AND SERVICES FOR CHILDREN AND ADOLESCENTS

Different Needs

Children and adults have different health care needs, and this becomes especially important in mental health and substance abuse services. Children are continually growing, developing, and changing, sometimes with unpredictable results. The pace of physical, emotional, mental, and social development during childhood and adolescence requires ongoing assessment within the context of what is culturally appropriate for the family.

Children with emotional disorders are in all kinds of families—wealthy, middle class, poor, some with insurance, some with no insurance, some eligible for public sector financing and programs.

Sybil Goldman

Georgetown University

Public Workshop, April 18, 1996, Washington, DC

Children are dependent on adults for protection and promotion of their well-being, including having the ability to recognize and seek assistance for health problems. Parents and other caregivers provide access to care through insurance coverage and other means, so children from low-income families can be at risk of being uninsured or underinsured and, thus, of having less access to care. Similarly, children whose parents or caregivers are impaired by substance abuse or other problems require additional supports and may be at higher risk of developing simi-

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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lar problems themselves. More than three-fourths of all foster children have parents who are addicted to drugs or alcohol or both (Children 's Defense Fund, 1994).

One of the best indicators of children's health status is performance in school, which is also one of the more consistent ways in which children are assessed and provided with care. In a recent population-based survey known as the Great Smoky Mountains Study of Youth, approximately 20 percent of the children met the criteria for a diagnosis of a mental health problem. Of those who had received care, most (70 to 80 percent) received services from practitioners who worked in schools, primarily guidance counselors and school psychologists. Approximately 12 percent had received services in the general medical sector, usually in combination with other kinds of services (Burns et al., 1995).

Child and Adolescent Service Systems
Nature and Extent of the Problem

An estimated 12 million children—20 percent of all children—experience some mental health or substance abuse problems while they are growing up, including attention deficit hyperactivity disorder, severe conduct disorder, depression, and alcohol and other drug abuse and dependence problems (CMHS, 1996; DHHS, 1991; IOM, 1989; OTA, 1986). An estimated 3.5 million children have serious emotional disturbances (CMHS, 1996). In 1990, state agencies fielded more than 1.7 million reports of child abuse affecting approximately 2.7 million children (National Center for Child Abuse and Neglect, 1992). By the age of 11, 1 in 5 children has smoked cigarettes and 1 in 11 children has had their first drink of alcohol (AMA, 1994; Johnston et al., 1995).

Pediatricians and other primary care practitioners are often the first health care professionals to be consulted when behavioral problems and emotional disturbances are noticed by parents or teachers. Guidelines have been developed to assist in the evaluation and treatment of mental health and substance abuse problems in adolescents, including psychosocial adjustment, eating disorders, use of alcohol and other drugs, depression, learning disorders, and emotional, physical, and sexual abuse (AMA, 1994). In Medicaid's early and periodic screening, diagnosis, and treatment program for Medicaid-eligible children under age 21, states are required to provide or arrange for “comprehensive, periodic assessments of their physical and mental health and follow-up services to diagnose and treat any problems discovered as part of the screening process” (NIHCM, 1996, p. 3). The extent of implementation of the guidelines, however, is not known.

Fragmentation in Financing

Once a problem has been identified, publicly financed care for children and adolescents comes from a variety of categorical programs, including Medicaid, the

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Maternal and Child Health Block Grant (part of Title V of the Social Security Act), mental health programs, social services, foster care, substance abuse services, school-based clinics, special education, recreation programs, and the juvenile justice system. Given the multiplicity of funding streams and fragmentation of responsibilities among these agencies, the coordination of care across all systems is almost impossible (Burns et al., 1995; England and Cole, 1995; Newacheck et al., 1995). Studies have shown that only about one-third of children with severe problems get the needed services (Brandenburg et al., 1990; DOE, 1993; Knitzer, 1982; Stoul et al., 1994).

Managed behavioral health care plans serving children and their families face the added challenge of providing family-centered services that need to interface with the multitude of systems that serve children.

Michael Faenza

National Mental Health Association

Public Workshop, April 18, 1996, Washington, DC

National policy for children's mental health services promotes “systems of care,” based on principles and values of the Child and Adolescent Service System Program (CASSP). Initiated in 1984 through the National Institute of Mental Health, CASSP was the first federally funded initiative responding to the needs of children and adolescents with serious emotional disturbances. Although in 1993 it was renamed the Planning Systems Development Program, the CASSP principles have wide support among state agencies, professional organizations, and advocacy groups concerned with children and adolescents. These principles include (SMHRCY, 1995):

  • case management;

  • coordination of care;

  • individualized treatment on the basis of need;

  • culturally competent services;

  • active involvement of families and surrogate families (e.g., foster care) in the development of treatment plans;

  • commitment to providing the least restrictive, most normative environment that is clinically appropriate.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Adolescent Treatment Issues

A unique challenge exists in providing developmentally appropriate services to adolescents with alcohol and drug abuse problems. Because of the historic fragmentation of public services to children, a comprehensive approach to serving the needs of adolescents has not evolved. Adolescent clients are served in a variety of settings, with treatment paid for by a variety of funds. Often, clients are served simultaneously in several systems or are referred from one system to another until they reach adulthood. In the absence of clinically coordinated treatment, the severity of the addiction often progresses.

During the 1970s, models of early intervention for alcohol- and drug-abusing youth evolved simultaneously in different locales. Private insurance often paid for traditional 28-day inpatient treatment for adolescents. Programs supported by a variety of funds attempted to develop unique approaches to intervening at the early-onset stages of substance abuse. With cutbacks in funds, many of these early efforts were ended, despite their promising results. There is a need to further evaluate what services should appropriately be developed to address adolescents with problematic substance abuse. Perhaps models from other adolescent interventions could be applied, for example, peer counselors, who are an important part of many teen pregnancy prevention models.

There was a young person who was not successful on any kind of inpatient treatment or intensive outpatient treatment or any of the programs. And we finally got him into a group home situation. The health plan paid for it and then they did a cost-benefit analysis. And they found that not only was it clinically effective, but it was incredibly cost effective.

Susan Goldman

John Hancock

Public Workshop, April 18, 1996, Washington, DC

The 1994 Institute of Medicine study Reducing Risks for Mental Disorders recommended further research on the effectiveness of interventions for children and adolescents and also recommended that the research efforts be coordinated. There is little research on the structural characteristics and components of interventions that serve children and adolescents, that is, child-serving and teen-friendly interventions, and that seem to produce the most favorable results (IOM, 1994). Much remains to be learned.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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CARE AND SERVICES FOR SENIORS

Contrary to stereotypes, most senior citizens view their health status in a positive way. A 1987 survey found that close to 70 percent of older adults living in the community viewed their health as excellent, very good, or good compared with the health of others their own age; the percentage reporting poor health was about 30 percent (NCHS, 1989). However, the incidence and prevalence of chronic illness do increase with age. More than four of five older persons have at least one chronic medical condition, although they do not necessarily experience significant limitations in their daily activities because of that condition (U.S. Senate, 1988).

An estimated 15 percent of older persons have symptoms of primary depression (U.S. Senate, 1988). This estimate does not include secondary depression, which can result from medication side effects or physical causes. Thus, depression may be far more prevalent than suggested by these estimates. Suicide is a more frequent cause of death among elderly individuals, particularly among elderly men, than among individuals in any other age group (IOM, 1990).

For seniors with multiple problems, such as medical and mental health problems, there is a great need for coordination of care. Demonstration programs such as the social HMO programs and the Program for the All-Inclusive Care of the Elderly pool Medicare and Medicaid funding and funding from private sources to coordinate medical and other services (IOM, 1995). These programs build on a team approach with primary care physicians, nurse practitioners, social workers, nutritionists, and others who participate in the joint planning and delivery of care.

With the increasing movement of Medicare populations into managed care plans, the Health Care Financing Administration has undertaken a project with the United Seniors Health Cooperative to help seniors become more informed consumers. In the words of Sarah Gotbaum (1996), a sociologist who directs the project:

Whether or not to join a Medicare HMO, which one to join, whether to remain in one, transfer to another, or return to fee-for-service —these are among the overwhelming concerns of millions of older Americans faced with entering the foreign world of managed care. The elderly, burdened with the aging process, increased illnesses, decreased incomes, decreasing family supports, changing lifestyles and security, are even more unprepared to identify what they must know in judging a plan, what questions to ask, whom to go to for unbiased, relevant information, whom to trust, what offering is best suited to their personal needs. Most health care choices made today are made on the basis of benefits and price. Consumers know little or nothing about the internal workings of managed care plans with respect to access, appeals, complaints, service denials, benefit restrictions, disenrollments, consumer satisfaction, quality of care. Consumers shopping for a plan should be able to compare HMOs on these dimensions (Gotbaum, 1996).

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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In 1996, more than 37 million Americans over the age of 65 were enrolled in the Medicare program, and about 10 percent of these individuals were in managed care plans (HCFA, 1996b). Many of the concerns of Medicare-covered individuals entering managed care plans are unique to the concerns of the elderly. As Dr. Gotbaum pointed out in her testimony to the committee, however, many of the concerns are shared by other purchasers: how to balance costs and benefits with the quality of services provided.

INDIAN HEALTH SERVICE

The Indian Health Service (IHS) was established in 1787 under Article I of the U.S. Constitution. An agency of the U.S. Public Health Service, IHS is responsible for providing health care to approximately 1.4 million American Indians and Alaska Natives residing in remote, isolated areas in 34 states. Services are provided through either IHS- or tribally-operated hospitals and clinics or through urban Indian projects. Only members of federally recognized Indian tribes and their descendants are eligible to receive the services provided by IHS (IHS, 1996a).

With a current annual appropriation of approximately $2.2 billion, IHS, like other public and private health care practitioners, must address the soaring costs of delivering health care. This mission is compounded by the lack of a health care infrastructure in the remote areas being served and by the fact that the overall health status of American Indians and Alaska Natives lags far behind that of other Americans (IHS, 1996a). For example, among American Indians and Alaska Natives the infant mortality rate in 1990-1992 was 9.4 per 100,000, compared with a rate of 7.3 per 100,000 among all other races in the United States (IHS, 1996b). For 1990-1992, the mortality rate from accidents among American Indians and Alaska Natives was nearly 2.7 times the age-adjusted rate among all races in the United States (83.2 compared with 31.0 per 100,000), and age-adjusted mortality from alcoholism was nearly six times that for the rest of the U.S. population (37.2 compared with 6.8 per 100,000) (IHS, 1996b).

To serve the American Indian and Alaska Native populations better, IHS has formed partnerships with tribal governments and other Indian organizations. As of March 1996, 64 health centers, 50 health stations, 37 hospitals, 34 urban health projects, and 5 school health centers formed the basis of the IHS system. The total clinical staff consists of approximately 2,580 nurses, 840 doctors, 380 dentists, and 100 physician assistants (IHS, 1996a).

Following the national trend, IHS is increasingly becoming an outpatient care delivery system, with ambulatory care visits increasing and hospital admissions declining. In 1993, outpatient visits totaled more than 5.5 million, compared with total IHS and tribal hospital admissions of 69,000 (IHS, 1996b). As patients become sicker and have more complex problems, such as complications from diabetes, IHS hospitals are seeking to develop referral relationships with

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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non-IHS tertiary care facilities. For example, in some locations, IHS hospitals have developed cooperative agreements with Veterans Administration hospitals (Cedar Face, 1996).

As of January 1995, all IHS- and tribally-operated hospitals and eligible IHS-operated health centers were accredited by the Joint Commission on Accreditation of Healthcare Organizations (IHS, 1995). In combination with the accreditation process, total quality management guidelines are requiring IHS facilities to restructure the ways in which they are organized and deliver services. Staffing patterns and the ratios of health professionals to patients at some clinics are being reevaluated to improve efficiency and cost-effectiveness.

With escalating health care costs, a growing population requiring services, and declining resources, IHS and its partners have committed themselves to the concept of managed care to ensure the delivery of cost-effective and high-quality health care. Although no comprehensive system has been established among the IHS- and tribally-operated hospitals and clinics, several communities have enacted aspects of managed care that have reduced costs, expanded services, and improved the quality of care. Some communities have established pharmaceutical cost-containment programs, day hospitals for mentally ill individuals, clinical prevention programs, practice management initiatives, telemedicine, and quality improvement programs (IHS, 1995).

One example of the role that managed care is having on IHS involves California's 1992 Managed Care Expansion Plan, which would bring managed health care to an additional 13 counties, including counties that serve thousands of American Indians. In 1993, the California Indian Managed Care Task Force was established to work with the state of California in expanding managed care into American Indian populations. Working with tribal leaders and 638 contract and urban Indian clinic administrators, the task force agreed to the following:

  • recognition of the concept of Indian tribal sovereignty, allowing Indian clinics to negotiate directly with the state on the extension of managed care;

  • acknowledgment, under P. L. 102-573, of the Indian clinics' right to provide health care first and foremost to American Indians and Alaska Natives;

  • recognition of the need of Indian clinics to provide culturally sensitive health care; and;

  • acknowledgment of the Indian clinics' federally qualified health center status—and, therefore, agreement to reasonable-cost reimbursement to the clinics—and acceptance of the automatic enrollment of Indian patients into Indian health clinics (IHS, 1995).

This task force has also begun negotiations with the state of California concerning managed care reform plans in the areas of dental and mental health. Working closely with the Health Care Financing Administration, the task force

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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is addressing the issues of Native American health care rights and the way in which the state or managed care plan will be reimbursed in these and other areas (IHS, 1995). Managed care and the role of quality assurance and accreditation guidelines have certainly become an integral part of IHS in providing both quality and cost-effective care to American Indians and Alaska Natives.

CULTURAL COMPETENCE

The United States is becoming increasingly multicultural: racial and ethnic minorities are the fastest-growing groups in the population of the United States. In 1990, Hispanics, Asians, and Pacific Islanders made up 19.7 percent of the total population, and by the year 2000 it is estimated that the proportion will have increased to 25 percent of the population (BOC, 1990). Thus, cultural differences between patients and practitioners are becoming more common, and these differences can have crucial implications for the quality and outcomes of care. For example, studies have indicated that there are ethnically based differences in treatment for pain (Todd et al., 1993) and disparities in health status between racial and ethnic minorities and the rest of the U.S. population (DHHS, 1991).

The literature, the science, and the body of knowledge about the effect of culture in providing mental health services or in being able to diagnose mental health problems is very important.

Raphael Metzger

National Coalition of Hispanic Health and Human Services Organizations

Public Workshop, April 18, 1996, Washington, DC

Cultural competence is a term that refers to the sensitivity, cultural knowledge, skills, and actions of practitioners that meet the needs of patients from diverse backgrounds (AMA, 1994). Cultural competence can be demonstrated in many ways, for example, by including cultural factors in history-taking and diagnosis, addressing language barriers by having multilingual staff or interpreters, and changing communication patterns to recognize cultural beliefs, practices, and roles, such as deference to elders (Oösterwal, 1994).

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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We put on the referral form the numbers the staff could call so we could provide translation while the patient was there. I realize these things are mundane, but this is the level you have to think at if you are talking about being able to provide for diverse patients.

Grace Wang

Association of Asian Pacific Community Health Organizations

Presentation to the Committee, June 29, 1996 Washington, DC

Several models and guides have been developed to promote cultural competence in service delivery to particular racial and ethnic groups. For example, the Association of Asian Pacific Community Health Organizations developed a manual on culturally competent managed care for Asians and Pacific Islanders, with support from the Bureau of Primary Health Care (AAPCHO, 1994). The manual describes the Language Access Project, a model that has been developed in community health centers serving predominantly Asian and Pacific Islander populations. The emphasis is on helping individuals with limited English proficiency to access health care services.

The National Coalition of Hispanic Health and Human Services Organizations has developed a manual for practitioners in the delivery of preventive services to Hispanic groups (COSSMHO, 1990), with funding from the U.S. Office of Disease Prevention and Health Promotion in the Office of the Assistant Secretary for Health. The manual provides background on general health characteristics of the Hispanic population, describes beliefs and practices that influence health status, and offers strategies for effective interactions between practitioners and patients.

Managed care raises issues regarding the determination of when steps need to be taken to provide culturally competent care. Known operationally as the “threshold” issue, these determinations can be made on the basis of the number of individuals who have language barriers or the percentages in the population (AAPCHO, 1994). In communities in which particular racial and ethnic groups are concentrated, the threshold issue may need to be approached differently than in multicultural communities, but there are no standards in this area.

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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In cities like New York or Los Angeles, there are up to 150 language groups. Requiring each health care entity to be responsible for all of those languages is a real problem. Seattle has created a community interpreter service program for a variety of different languages, and interpreters can be dispatched to hospitals on scheduled or on-call basis. They hire Spanish-speaking providers or interpreters as staff, and then rely on the interpreter pool for the less frequently used languages.

Julia Puebla Fortier

Resources for Cross-Cultural Health Care

Presentation to the Committee, June 29, 1996 Washington, DC

A culturally-competent system of care values diversity, has the capacity for cultural self-assessment, is conscious of the dynamics inherent when cultures interact, has institutionalized cultural knowledge, and has developed adaptations to diversity.

Grace Wang

Association of Asian Pacific Community Health Organizations

Presentation to the Committee, June 29, 1996 Washington, DC

California's MediCal managed care system moved from determining thresholds on a percentage basis to using absolute numbers (AAPCHO, 1994). One guide for California's strategic plan for the MediCal conversion to managed care was a study supported by the Health Resources and Services Administration, which identified the ways in which bilingual and bicultural practitioners change their practice patterns when they serve non-English-speaking Latino and Chinese patients (Tirado, 1995). The study distinguished between cultural competence, “a level of knowledge and skills to provide effective clinical care to patients from a particular ethnic or racial group” and cultural sensitivity, “a psychological propensity to adjust one's practice styles to the needs of different ethnic or racial groups ” (Tirado, 1995, p. 1).

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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In some communities, community-based racial and ethnic groups form coalitions to develop resource networks. For example, the Latino Coalition for a Healthy California, the Asian Pacific Islander Health Forum, and the California Black Health Network are part of California 's Multi-Cultural Health Information Project, which is developing a database of health care experts and resources. The desire for contact with a practitioner of similar racial and ethnic background is difficult to satisfy, since racial and ethnic minorities are underrepresented among health care professionals (COSSMHO, 1990).

We are hearing more and more now that managed care organizations are really seeing linguistically and culturally diverse populations as a niche they can approach within the marketplace.

Julia Puebla Fortier

Resources for Cross-Cultural Health Care

Presentation to the Committee, June 29, 1996 Washington, DC

A general discussion such as this one cannot begin to capture the richness and variation among and within this country's racial and ethnic groups. However, it is clear that the diversity provides a significant challenge to managed care organizations in being responsive to cultural preferences among the populations that they serve.

RURAL HEALTH AND MANAGED CARE

According to the U.S. Bureau of the Census, a rural area is defined as a county without a central city or two cities of 50,000 or more in population or as a county or town with areas of open country or fewer than 2,500 people. Nearly 23 percent of the U.S. population live in rural areas (BOC, 1988, 1989). Health care delivery and financing in these areas are often confronted with low numbers of physicians, financially fragile hospitals, low incomes, and low population densities. Although the extent and number of managed care delivery systems in place in rural areas is unknown, that number is growing. Managed care plans in rural areas are hoping to help improve health care availability and affordability.

Managed care plans in rural areas appear to be more successful when they are built around physicians instead of hospitals, since practitioners usually control both the hospital and specialist referrals in such an area. Physicians often feel overworked and underpaid in rural areas, but they will enroll in managed care networks to maintain their patient base. Point-of-service plans and HMOs may

Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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provide rural physicians with the greatest market share benefits, because managed care plans offer additional benefits to employees to use their designated primary care physicians (NRECA, 1991).

Managed health care plans in rural areas provide communities with opportunities to reduce health care costs, enhance the financial viability of practitioners, and overcome distances and isolation that can reduce the quality of health care in these areas. Within managed care plans, health professionals are selected on the basis of their credentials and ongoing performance, ensuring that the outcome and the impact of care on the patients indicate that the care is of the highest quality (Christianson, 1989; NRECA, 1991).

However, other factors, such as the enhanced role of primary care physicians, the focus on the cost-effectiveness of care, and the changes that have been made at both the state and federal levels, have also led the way in fostering changes in rural medical practice. Issues surrounding the uninsured, the relative scarcity of practitioners, low population densities, and low incomes still need to be addressed in relation to rural health care. Such factors do not generally restrict the usefulness of managed care, but managed care can provide opportunities and alternatives to overcome those problems (Korczyk, 1989; NRECA, 1991.)

SUMMARY OF STRUCTURAL ISSUES

This review of system structures illustrates the complex organization and financing systems required to provide mental health and substance abuse services, documents the presence of multiple autonomous but overlapping systems of care (public, private, DOD, and IHS), and recognizes the fragmentation inherent in developing services for distinct populations (e.g., children, adults with chronic problems, various cultural groups, and consumers in both urban and rural areas).

Standards of care, accreditation guidelines, and quality improvement mechanisms that address system integration are one way to overcome fragmentation in the delivery of care. Integrated delivery systems are transforming the delivery of care in the public and private sectors in different ways and are also creating new needs for quality measurement systems that keep pace with evolving structures and other new developments in the delivery of care.

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Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Suggested Citation:"STRUCTURE." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Managed care has produced dramatic changes in the treatment of mental health and substance abuse problems, known as behavioral health. Managing Managed Care offers an urgently needed assessment of managed care for behavioral health and a framework for purchasing, delivering, and ensuring the quality of behavioral health care. It presents the first objective analysis of the powerful multimillion-dollar accreditation industry and the key accrediting organizations.

Managing Managed Care draws evidence-based conclusions about the effectiveness of behavioral health treatments and makes recommendations that address consumer protections, quality improvements, structure and financing, roles of public and private participants, inclusion of special populations, and ethical issues.

The volume discusses trends in managed behavioral health care, highlighting the emerging role of the purchaser. The committee explores problems of overlap and fragmentation in the delivery of behavioral health care and discusses the issue of access, a special concern when private systems are restricted and public systems overburdened.

Highly applicable to the larger health care system, this volume will be of particular interest to all stakeholders in behavioral health—federal and state policymakers, public and private purchasers, health care providers and administrators, consumers and consumer advocates, accrediting organizations, and health services researchers.

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