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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH
est risk for health and mental health and substance abuse problems: individuals in poverty, racial and ethnic groups, and others with special needs (Shortell et al., 1994).
The measurement of access is an extremely important area of concern for purchasers and for consumers. No valid and reliable technology exists to measure access, which is assessed in a variety of ways: access to clinicians, to initial and follow-up appointments, to appointments with clinicians of choice, at time of day of choice, and so on. Satisfaction with access is one important source of information, but additional measures need to be conceptualized, developed, tested, and implemented.
NEEDS OF SPECIAL POPULATIONS
Considering the fit between service need and access also means taking into account variations in need among different groups, particularly differences associated with gender and race or ethnicity. The issue of fitting special services to special needs is particularly relevant to ethnic and gender subgroups. Utilization of services in general and of particular types of services varies by gender and ethnic groups according to treatment and national survey data, but it is not known if this is due to discrimination (e.g., selective screening at admission, including insurance criteria that exclude those without proper health profiles), to a lack of interest and denial of the problem, or to the fact that appropriate services that would attract such groups are not made available to them.
Different population groups have different problem profiles, are differentially represented, and have different treatment needs and issues related to access. For example, women's substance abuse treatment needs often differ from men's (De Leon et al., 1982; Reed, 1987), particularly because of their higher rates of childhood sexual and physical abuse and victimization (Wallen, 1992) and also because women may have fewer economic resources and social supports available (Anglin et al., 1987; Harrison and Belille, 1987; Weisner, 1993; Weisner and Schmidt, 1992). Drug addicts who are pregnant have been identified as a group that could become involved in the prevention of chronic medical conditions in children (Weisner, 1996).
Ethnic and Racial Differences in Substance Abuse
It is also important to consider ethnic and racial differences when examining availability and access to services. Ethnic minorities are overrepresented in the public system and are underrepresented in the private system, and this poses special considerations as the public system increasingly contracts with managed care organizations. Rates of need for services differ by age, socioeconomic status, and