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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-



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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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-

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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)

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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-

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 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. REFERENCES AAFP (American Academy of Family Physicians). 1996. Family Medicine Online. [http:// www.aafp.org]. October. AAMFT (American Association of Marriage and Family Therapy). 1996. A Consumer's Guide to Marriage and Family Therapy. Washington, DC: American Association of Marriage and Family Therapy. AAPA (American Academy of Physician Assistants). 1996. AAPA Homepage: General Information. [http://www.aapa.org]. September.

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