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ture that was designed to reduce costly inpatient admissions while allowing more use of less expensive outpatient treatment (Callahan et al., 1994). Typically, however, such incentives are not in place, and there are no protections to ensure that individuals are able to receive the most appropriate care that is available to them. The committee believes that access to care must be monitored carefully to ensure that individuals in need of mental health and substance abuse services receive prompt and appropriate care. Because private insurance and health plans often limit benefits for mental health and substance abuse services and because public systems of care serve individuals with high levels of disability and vulnerability, access to services must be monitored in both systems.

The reasons for monitoring access to care within managed care plans are outlined in this chapter. Current approaches to the measurement of access are also reviewed. Finally, the need for a broader approach to the measurement and evaluation of access is examined.

IMPORTANCE OF ASSESSING ACCESS

Historically, either a lack of coverage for mental health and substance abuse services or limited benefits restricted access to and the utilization of treatment for mental health and substance abuse problems (Frank and McGuire, 1996; McGuire, 1981, 1989; Rogowski, 1992, 1993; Scott et al., 1992). Although some states passed legislation that required that commercial group health care plans include coverage for mental illness and alcoholism, the benefits were limited and many states simply required that coverage be offered (Scott et al., 1992). Services for drug abuse and dependence were rarely specifically included in health plans (Rogowski, 1993), although plans tended to extend coverage for alcoholism treatment to other drugs of abuse.

Even in the public sector, Medicaid coverage for mental health and substance abuse treatment tends to be limited (Horgan et al., 1994; Larson and Horgan, 1994; Solloway, 1992). Copayments have also been used to discourage service utilization. Moreover, a large portion of the population and a disproportionate number of individuals with mental health and substance abuse problems are uninsured and dependent on publicly funded services. Public systems of care limit access through the use of strict eligibility criteria: individuals must be categorically eligible for Medicaid and must usually meet “most-in-need ” criteria for serious mental illness to receive care in state mental health systems. Access to mental health and substance abuse benefits was therefore problematic even before the introduction of managed care.

Even more threats to limit access may exist within a managed care environment. Self-insured employers can design benefits packages without regard to state mandates for mental health and substance abuse coverage. Capitated health plans and practitioners may have incentives to deny access to expensive levels of care and even to deny care (Woolhandler and Himmelstein, 1995). Utilization man-



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