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6

Process

In general terms, measurement of the quality of health care is driven by different forces in the private and public sectors. In the private sector, quality measurement is a reflection of the requirements of the accreditation process and, increasingly, is also a response to the demands of employers and other purchasers through contracting, report cards, and other means. In the public sector, performance measurement is the primary tool of accountability for spending public funds on health care (DHHS, 1995; IOM, 1989a).

This chapter begins with a general discussion of quality and accountability in the private sector, an overview of methods of quality improvement, and a comparison of current quality improvement methods in managed behavioral health care. Next is a discussion of performance measurement, model standards, and related developments in the public sector. The chapter then provides an overview of the accreditation process, including the development of standards and descriptions of five organizations currently in the accreditation industry. The chapter concludes with a discussion of the role of government in quality assurance.

QUALITY AND ACCOUNTABILITY

Background

Health care purchasers are caught in a dilemma created over the past 50 years and for which there is no easy resolution. Following World War II, the U.S. economy was strong and its industry dominated the world marketplace. Jobs were plentiful, and employers competed for skilled workers. The American ethic of a



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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 6 Process In general terms, measurement of the quality of health care is driven by different forces in the private and public sectors. In the private sector, quality measurement is a reflection of the requirements of the accreditation process and, increasingly, is also a response to the demands of employers and other purchasers through contracting, report cards, and other means. In the public sector, performance measurement is the primary tool of accountability for spending public funds on health care (DHHS, 1995; IOM, 1989a). This chapter begins with a general discussion of quality and accountability in the private sector, an overview of methods of quality improvement, and a comparison of current quality improvement methods in managed behavioral health care. Next is a discussion of performance measurement, model standards, and related developments in the public sector. The chapter then provides an overview of the accreditation process, including the development of standards and descriptions of five organizations currently in the accreditation industry. The chapter concludes with a discussion of the role of government in quality assurance. QUALITY AND ACCOUNTABILITY Background Health care purchasers are caught in a dilemma created over the past 50 years and for which there is no easy resolution. Following World War II, the U.S. economy was strong and its industry dominated the world marketplace. Jobs were plentiful, and employers competed for skilled workers. The American ethic of a

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH benevolent employer was firmly reinforced by years of unions' struggles with management and by a healthy economy under which employers could afford to offer generous health benefits. For years, the health insurance contract offered ever-increasing benefits, freedom of choice, and first-dollar coverage (few copayments or deductibles). Employers trusted their employees and providers. Although consumers and providers struggled for many years to develop more adequate mental health and substance abuse benefits, most people were happy with the health care system. Furthermore, the U.S. Congress initiated the Community Mental Health Centers Act, Medicare, Medicaid, Hill-Burton, and other programs (see Chapter 3), which contributed greatly to the growth of the health care industry. With these investments, the public and private sectors created health care access and resources that were unparalleled in world history. Fueled by scientific prowess and expanding financial commitments, the health care system appeared to have no limits in its potential capacities to provide health care. However, unlimited growth could not continue. With the rising costs of health care services threatening the financial stability of their budgets, private and public payers increasingly turned to methods that make health care accountable and affordable and that prevent cutbacks in previously reimbursed health benefits. The widespread initiation of utilization management, health maintenance organizations (HMOs), and other managed care methods during the past quarter century has emphasized cost accountability (IOM, 1989a). These programs have cumulatively evolved into an industry and have become a strong force in the health care system. Consumers and providers who believe that autonomous health resource decisions on the basis of tradition and the health care contract are consequently in conflict with such policies. The tensions over cost controls have increasingly focused concerns about cost-containment efforts on quality issues such as the following: qualifications of and consumers' geographic access to a comprehensive range of providers; prevention of avoidable illness and provision of timely and focused treatment interventions; availability of services, on the basis of urgency of need; courtesy, convenience, and comfort of services; compassion and kindness of care; competence of providers to institute most appropriate evaluations and treatments, which would result in services that would result in the least risk to the patient and with the best health status outcome; and administrative efficiencies of health care services that promote quality through effective communications, consumer and provider education, decision support, and quality management, treatment coordination, and other systems.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH The interest in quality is reinforced by consumer demand and empowerment, professional ethics, legal and regulatory interpretation of citizens ' rights, and attempts by businesses to satisfy and keep customers in a competitive health care marketplace. For public purchasers who are accountable for public funds, it is important to demonstrate that health care has good value and is worth the investment. The next section will give an overview of different methods for assessing quality. Methods for Quality Assessment Accreditation One of the more traditional methods of quality assessment, accreditation of hospitals and managed care organizations, has evolved over the past 60 years to include highly specialized and involved accreditation of facilities, programs, and systems by numerous national accrediting entities, both voluntary and governmental. In addition, many managed behavioral health care organizations have developed “certification ” methods based on various quality parameters and sources to establish the qualifications of various institutional and professional providers that are contracted into their networks. Managed care accreditation has become increasingly popular for public- and private-sector health programs because it is viewed as the best current system for creating accountability and quality, even though there is limited evidence to support the relationship between adherence to quality standards and improvements in patients' health status. Accreditation will be discussed more fully in a later section of this chapter. Professional Review of Care Review of care by peers or other qualified health professionals has been practiced extensively, especially in professional case conferences and for granting credentials and privileges. Peer review has become more institutionalized, detailed, and systematically applied in recent years with the evolution of the utilization management and quality assurance movements. Concerns by payers, courts, and facilities about the medical appropriateness of care have led to broader applications of professional review to prospectively, concurrently, and retrospectively validate clinical decisions made by clinicians for individual patient care and care for populations of patients. Licensing States have licensed physicians and nurses for many of the past 75 years through examinations and the recognition of professional training in accredited programs. Licensing has expanded substantially to other health care practitioners

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH and has become more prescriptive regarding the scope of practice limits in many jurisdictions. In addition, it has been tied in recent years to continuing education requirements, proof of competence, and both sanctions and supervision in instances in which impairment is established. Licensing of facilities has likewise become a major state function, involving monitoring of numerous and varying requirements established by state legislatures and regulatory agencies. Credentialing and Privileging Health care programs provide risk and quality management through a number of approaches. They and accreditation organizations have established standards of practitioner competence based on such factors as training in accredited health professional programs, possession of a current state license, professional certification, demonstration of specific technical skills under expert supervision, evidence of liability coverage and acceptable prior malpractice experience, and attestation to the existence of no current health conditions that would expose patients to risks. Programs now commonly have dedicated resources to establish primary source verification of practitioners ' qualifications, to conduct initial and ongoing peer review of practitioners ' skills, and to restrict a clinician's practice and to report defined infractions to various state agencies and national data banks. The complexities and multiple requirements imposed on providers to account to many agencies and managed care organizations and managed behavioral health care organizations has caused credentialing-privileging to become a costly and time-consuming enterprise for both organizations and individual practitioners. The evolution of integrated credentialing systems could substantially reduce these burdens and maintain protection for the public. Physicians who have contracts with multiple organizations tell us that they can have as many as 20 or 30 reviews in a year, each of which looks at similar but just a little bit different criteria. Linda Bresolin American Medical Association Public Workshop, April 18, 1996, Washington, DC Auditing A number of quality-focused activities have evolved from purchasers ' needs to account for costs and regulators' needs to account for risks. The Health Care

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Financing Administration (HCFA) regularly conducts audits of the Medicare and Medicaid programs using both staff financial auditors and professional reviewers, including evaluations from state peer review organizations. Explicit survey standards and procedures are followed in these evaluations of agencies' and providers' statutory responsibility to provide services that are of acceptable cost, quality, and risk. Other agencies are substantially involved in developing standards affecting quality of care (e.g., the Substance Abuse and Mental Health Services Administration [SAMHSA] and the Agency for Health Care Policy and Research [AHCPR]) and in inspecting health care providers for compliance with quality-related requirements (e.g., the Occupational Safety and Health Administration). In the private sector, a number of health benefits consulting firms have hired clinicians, including mental health professionals, to develop clinical services standards, auditing instruments and methods, and quality improvement programs for their customers, which include purchasers and provider organizations. Of any single institution, these consulting firms have collectively had one of the most profound and least publicized impacts on managed care. Their influence over the managed care purchasing decisions of health plans, through the promotion of their performance requirements, selection of managed care organization and managed behavioral health care organization vendors, and auditing of managed care operations, has been a major contributor to the development of monitoring standards and systems embraced by other organizations (e.g., American Managed Behavioral Healthcare Association [AMBHA] and the National Committee for Quality Assurance [NCQA]). Courts The legal system, guided by tort principles and case law, provides an uneven but sometimes effective means of regulation in situations in which a lack of attention to quality of care can result in risk or harm to patients. Legal mechanisms serve as an arbitrator and financial compensator in situations in which grievances or harm are established to be the result of neglect or malpractice by the health care provider. The substantial growth of risk management programs in health care plans, initially propelled by the need for liability control, has also been accentuated by their incorporation into quality improvement activities. Clinical Practice Standards and Guidelines The opportunities for high-quality clinical care are enhanced when providers follow steps in evaluation and treatment that have evolved over years through scientific research and clinical experience. Clinical texts by authoritative specialists and published articles in reputable peer-reviewed journals represent a traditional source of clinical standards. In recent years, expert consensus panels have

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH proliferated to guide clinicians toward optimal decisions through their promulgation of specialized standards for a variety of conditions and medical technologies. A variety of published and unpublished standards, criteria, guidelines, indicators, and protocols have flooded the landscape of health care, resulting in sometimes differing views about medical appropriateness by various expert panels. Nevertheless, empirically and experientially based clinical standards constitute an essential method by which clinical decisions can be independently evaluated through professional review and indicator-based measurements. Consumer Satisfaction Concern about the satisfaction of patients and patients' families with health services by providers or regulators was uncommon until recent years. The growing power of consumers in a competitive market economy has migrated from other areas of business to health care, underscoring the essential importance of routinely assessing what consumers think and feel about their health benefits and services. Health services research has shown that patient satisfaction is one of the most relevant markers for quality, even if it is not always a sensitive indicator. Significant resources are being allocated to refine specific methods of assessing quality through consumer evaluation and to systematically seek customers' opinions in designing clinical services and improving the quality of clinical services. National and local newspapers and magazines provide consumers with information by comparing different health plans, including the results of consumer satisfaction surveys and other data available from report cards. The media also cover stories about provider “gag rules,” denials of services, problems with care, HMO profits, and other information that have unmeasured effects on disenrollment or other indications of dissatisfaction. QUALITY MANAGEMENT IN BEHAVIORAL HEALTH CARE Quality management activities in behavioral health care services have evolved over the past 30 years. They originated with the academic and professional bases of medical quality assurance (Mattson, 1992; Rodriguez, 1988), and have blended with traditional local practice (e.g., clinical privileging), state regulatory (e.g., licensing), and tort interventions to provide implicit and explicit oversight of health care quality. One of the major initiatives in the accountability of behavioral health care quality was instituted by the U.S. Department of Defense in 1975 to provide explicit oversight over psychiatric residential treatment for child and adolescent services under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). As noted in Chapter 4, this national initiative was the first by a national payer to establish specialized program standards and admission-treatment criteria for mental health services. Its evolution into a national peer review

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH program (Rodriguez, 1985) for inpatient psychiatric and outpatient psychiatric and psychological services became the foundation for private health plans' rapid embrace in the early 1980s of commercial utilization and quality management programs. In the latter part of the 1980s, indemnity health plan administrators realized that utilization management approaches such as retrospective and concurrent review had limited impacts on both costs and quality. Utilization management and employee assistance program vendors were encouraged to develop contracted networks of mental health providers to allow for mixed reimbursements and capitation of services and to better promote network-based quality management. In less than 10 years this phenomenon grew to the point that now more than 120 million people with insured or entitled behavioral health care benefits receive care in one of these managed care arrangements (HIAA, 1996). Employers as Purchasers of Behavioral Health Care Managed behavioral health care organizations have encouraged the documentation of efforts to account for quality of care and services. Xerox, IBM, GTE, and Digital Equipment Corporation have led the way in establishing quality specifications for their managed behavioral health care organization vendors. Through the imposition of contract guarantees, corporate purchasers reward quality and penalize poor service. Employers are increasingly concerned about the quality of care that 's being provided to their employees, and they want to gather more data on it. It's not self-reported through the health plans, so they need to look to groups that have the market power as well as the relationships with the health plans to gather that data collaboratively and in an audited format. Catherine Brown Pacific Business Group on Health Public Workshop, May 17, 1996, Irvine, CA Contract-based performance standards have become the base for industry and voluntary accreditation organization standards, notably those developed by AMBHA (1995) and NCQA (1996a, b). Some payers have developed their own explicit requirements for HMOs that provide care under their health benefits

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH plan for such areas as member services and satisfaction, administrative services, organizational structure and philosophy, provider credentialing and performance monitoring, clinical services management, clinical delivery support systems, and confidentiality. Digital Equipment Corporation, for example, has specific requirements for the behavioral health services that it purchases: benefit design, access, triage, treatment approach, case management, alternative treatment settings, outcomes measurement, quality management, and prevention and early intervention. Table 6.1 compares some of the more widely used behavioral health care standards. Trends in Quality Standards in the Private Sector Because so many purchasers' efforts to become involved in prescribing methods and outcomes goals for quality accountability are in the early stages and because the state of population-based measurement systems is not refined, quality management in behavioral health and other clinical services is in the early stages but is evolving rapidly. As with most evolutions, an experimental phase precedes consensus about what constitutes the best approach. In addition to the standards listed in Table 6.1, numerous employer coalitions, both local and national, are now embarked on efforts to establish performance requirements for managed care. Examples include the Managed Health Care Association, the Employer Consortium, the National HMO Purchasing Coalition, the Minnesota Buyers Healthcare Action Group, and the Pacific Business Group on Health. Many of these coalitions have significant participation by health services consumers and their representatives, such as unions, advocates, organizations, and insurance commission agencies. The Foundation for Accountability (FACCT), representing a broad coalition of public and private purchasers and others, has begun to develop and test tools that will allow documentation of population-specific functioning, quality of life, satisfaction with services, and risk reduction for a number of medical conditions commonly seen in health plans, such as diabetes, asthma, breast cancer, coronary artery disease, and low back pain (FACCT, 1995). Mood and anxiety disorders represent other conditions whose prevalence and direct and indirect

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH costs and for which there are problems in the quality of evaluation and treatment are of great concern. TABLE 6.1 Cross-Comparison of Managed Behavioral Health Care Performance Indicators Indicator AMBHA: PERMS Digital Equipment Corporation NCQA: HEDIS (Medicaid and 3.0 Draft) SAMHSA: MHSIP Population Populations served by carve-out behavioral health care organizations; mostly employed individuals, and their dependents Employed population and their dependents in an HMO Employed population and their dependents; publicly supported populations including children Employed populations and their dependents; publicly enrolled populations including children and the disabled Access to care: Time frames Patient satisfaction with access experience: First appointment Intake process Call abandonment rate On-hold time Call answer time Establish the following time frames for access: Nonurgent, 10 days Urgent office visit within 48 hours Emergency, within 48 hours Telephone response: 90 percent in 20 seconds and not more than 5 percent abandoned call rate Waiting time to appointment Specific minimum time frames for access to emergency care within 4 hours, urgent care within 24 hours, and nonurgent care within 5 days Waiting time for telephone to be answered Average length of time from request to first face-to-face meeting with mental health professional Convenient location of services Convenient appointment times Easy-to-reach providers Access to Care: Range of services Penetration approach Percentage receiving services by age and diagnostic category Percentage receiving services by treatment setting, age, and diagnostic category Percentage receiving services by clinician type Overall rate of receiving services Ratio of health professionals not less than 45:1,000 Number of providers in each specialty service: eating disorders, children, adolescents, elderly, dually diagnosed, culturally appropriate, psychotropic medication management Geographic disbursement of alternative services (halfway houses, respite care, etc.) Percentage of mental health providers who have Medicaid beneficiaries in their panel and those whose panels are open to new Medicaid beneficiaries Report units of transportation services Availability of mental health/chemical dependency providers: Full range of services, with benchmarks for: Average resources spent on mental health Proportion of services that are consumer-run Proportion of services provided in natural settings (home, school, and work) Proportion for whom services are readily available

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH       Who accept new members with no restrictions (open panels) Who accept new members with some restrictions Who accept no new members (closed panel)   Access to care: Demographically (ethnic, language, and culture) appropriate services Not stated Not stated Defines plan beneficiaries' demographic characteristics by contact subtypes (i.e., SSI, AFDC, regular, etc.) Defines and reports the number of culturally-competent providers Percentage who report that staff are sensitive to ethnicity, language, culture, and age Percentage who had only one contact in a year Percentage of SSI and SSDI recipients who received services Access to care: Barriers to service Covered by other categories EAP direct referral to providers Direct referral in a closed HMO system by triage, primary care, EAP, and self Report units of transportation services Percentage for whom cost is an obstacle to service utilization Measurement of appropriateness of treatment Availability of medication management: number of cases of schizophrenia in last year with (1) ≤3 medication review visits and (2) ≥4 medication review visits Frequency of family visits for children age 12 and under Appropriate utilization of resources for adjustment Triage performed by appropriately credentialed staff Criteria for treatment are based on clinical research and acceptable industry standards Established criteria for determining the need for case management Mental health discharge rate per 1000 enrollees and average length of stay Percentage receiving any inpatient day/night or ambulatory mental health services by age and gender Number of enrollees hospitalized for major affective disorder and percent readmitted within 90 and 365 days Percentage who actively participate in treatment decisions Percentage who feel coerced into treatment options or services Proportion of inpatient admissions that are involuntary Proportion of services that promote recovery

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH   disorder cases in categories of ≤10 and ≥10 individual sessions   4. Ambulatory follow-up within 30 days post-hospitalization for major affective disorder Proportion of people who receive ambulatory services within 7 days of discharge from inpatient treatment Proportion of people who receive ambulatory services within 3 days of discharge from emergency care Percentage who change their primary mental health professional Treatment outcome measures Effectiveness measures Chemical dependency treatment retention measured by number and distribution of detoxification patients who had no additional detoxifications for 90 days and those with one or more detoxifications within 90 days Continuity of care: distribution of post-discharge mental health/ chemical dependency cases with no follow-up, follow-up contact, contact plus readmission, or readmission only Measure functional capacity Measure treatment outcome Analyze aggregated data for quality Conformance with HEDIS Effectiveness and utilization measures: Availability of mental health/chemical dependency providers Descriptions of pediatric mental health network (Medicaid only) Utilization of inpatient and ambulatory care Measures in testing: Substance abuse counseling for teens Continuity of care for substance abuse Medication management for schizophrenia Percentage who are connected to primary care Differential evidence of mortality due to medical causes Average level of involuntary movements from psychotropic medications Decreased level of psychological distress Increased sense of personal dignity Reduced level of impairment Increase in productive activity and competitive employment

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH validity of accreditation. The accreditation industry is faced with pressure to focus its standards on the relevant issues, collaborate with similar organizations, and consolidate the multitude of accreditation standards to reduce overlap and redundancy. The Accreditation Process The accreditation process entails generating standards and then comparing the actual delivery of care with the standards. There are at least seven distinct steps: Measures of performance, also known as parameters, are identified and recommended as standards. A process of review leads to acceptance of the standards. The standard is generally tested internally (“alpha” tested) and then tested on a external site (“beta” tested). After testing, the standards are incorporated into a review process. Organizations desiring to be accredited apply to be surveyed. A site review is performed by peer surveyors who examine the inner workings of the organizations against the standards. Finally, a process of scoring is developed to determine the organization 's degree of compliance with each standard and whether the aggregated results reached the threshold for granting accreditation. These steps are described in the following section. A standard, according to Donabedian (1982), is a professionally developed expression of the range of acceptable variation from the norm. A standard has also been defined as the desirable and achievable (rather than the observed) performance or value with regard to a given parameter (Slee, 1974). A parameter is an objective, definable, and measurable characteristic of the process or the outcome of care (e.g., access to behavioral health care within 5 days of a request in a nonurgent situation). Each parameter has a scale of possible values. For example, a geographic access parameter might require outpatient mental health services to be available within 30 minutes of a consumer's home or workplace. Variables would include, for example, traffic patterns in a busy urban setting where traveling 5 miles could take 1 hour during rush hour. Another variation might be in a rural setting, where there is a scarcity of consumers and services and travel time may be longer because of distance. The development of the current accreditation standards is based on professional consensus. The extent and diversity of opinions into the consensus process vary from agency to agency, as well as from standard to standard. Some agencies use a wide range of experts and elicit public participation, whereas others may use a closed panel of experts and a board review-editing procedure to develop a standard. The scope and relevancy of the standards by this process are dependent on

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH the input and consensus from all the affected parties. The process of standardizing different views from participants in the development of a standard is not clearly outlined in the public information provided by CARF, COA, JCAHO, NCQA, or URAC. Unless the accreditation process incorporates principles of quality in establishing standards and the survey process, there is a danger of inconsistency, variance, and unreliability. There are many opportunities in the accreditation process for variance in measures, interpretations, and dispositions, leading to disparate outcomes. The process of accreditation is heavily dependent on the strength of the standard as described, the surveyor's interpretation of the standard, and the applicability of the standard to a real situation. Accreditation standards written with admirable intentions may not lead to consistent interpretation and/or applicability to the real world. For example, COA has included a standard to define the scope of an agency's mission. It states that the primary purpose of an agency is to provide services to meet the needs of the community for protection, maintenance, strengthening, or enhancement of individual and family life and social and psychological functioning (COA, 1996a). This standard demonstrates responsible intentions but is subject to much variation in interpretation by reviewers and variability in what is considered to be the supporting evidence. During the training of surveyors, it would be important to outline the different variables in this standard. Reviewers should be familiar with the variations to the standard so they are able to assess during a review whether the nuances of the agency comply within the boundaries of the standard. Therefore, the accreditation label is only as good as the process of accreditation, from the development of the standards through the process of scoring. It is important in the accreditation process that: Standards are developed through a rigorous process of extensive peer consensus, a review of scientific evidence when applicable, and reevaluations of normative data to determine the true range of acceptable variations. Standards are objective, measurable parameters specific enough to minimize variations in interpretations by reviewers and the public. Standards are reviewed for their relevance and importance to the goal of accreditation and the integrative needs of the public. The validity and reliability of a standard must be known and reflective in the scoring, such that those standards with much variability are given less value than those for which there is stronger consensus. The implementation process is updated frequently, and there is a clear and recurrent process for establishing inter-rater reliability among reviewers. The final accreditation dispositions are compared with (trended against) acceptable parameters, that is, informed public perception, as a strong indicator of the competency of the accreditation process.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH INFORMATION INFRASTRUCTURE FOR QUALITY MEASUREMENT Administrative data sets are frequently a basis for quality-of-care assessments and are used in systems such as HEDIS 3.0 (NCQA, 1996a) and Performance-Based Measures for Managed Behavioral Healthcare Program (AMBHA, 1995). The data sets include claims data, records on visits and procedures, and, with the introduction of computerization, medical records. These information systems generally include relatively large pools of individuals and therefore permit analyses of specific practitioners and facilities (profiling), examinations of selected conditions and diagnoses, and changes in patient status over time. Because the data are collected for ongoing management functions (e.g., billing), they provide a relatively inexpensive source of information. Unfortunately, the value of the data sets for assessments of quality are limited because they are designed for management functions like billing and claims payment and may not include sufficient detail to facilitate analyses of quality of care (Garnick et al., 1994). Garnick et al. (1994) have noted that quality-of-care assessments require information on the utilization of care (e.g., visits, services, procedures, site of service, diagnoses, and outcomes), patient characteristics (e.g., age, gender, race, and employment status), and health plan descriptors (e.g., benefit structure, copayments). Many systems, however, do not include all utilization information and may not contain detail on the services provided. Plans with high deductibles and/or copayments may not record service utilization if it does not exceed the deductible, and high copayments may discourage individuals from seeking care. Plans may also fail to record the use of services when utilization exceeds the maximum benefit either because the individual seeks services outside the plan or the plan does not track self-paid services. Claims data are often insufficient to identify specific service dates (especially when multiple services are provided within a short period of time), procedure codes may not reflect the actual services provided, and diagnostic codes may be inaccurate or incomplete. Finally, commercial data sets often include limited information on patient characteristics and may not provide accurate information on the numbers of individuals enrolled at a point in time. Public-sector data sets often have more patient information because public policy requires the tracking of the services provided by age, race, and gender. These limitations are particularly problematic in the assessment of the quality of behavioral health care. Out-of-plan utilization is a major source of potential bias. The benefits for the substance abuse and mental health care and services provided within a plan are limited. Individuals with such problems often require more than the benefits offer, and turn to publicly-funded programs for additional care. Thus, a review of the services provided to an individual may suggest that he or she received one episode of care from the health plan for a short duration and no readmissions. If it were known, however, that the individual had received additional public services, the assessment of that plan's quality might change substantially. Moreover, procedure codes for ambulatory services may not differenti-

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH ate mental health and substance abuse care (NCQA, 1996a, b). For example, new admissions for mental health problems can be misinterpreted as readmissions for substance abuse if there had been an earlier substance abuse treatment episode. Finally, the lack of data on patient characteristics means case mix adjustments may not be feasible and makes it difficult to assess biases in patterns of care and the need for culturally and gender-specific services. Despite these limitations, administrative data sets are an efficient and important source of information for the assessment of quality of services. Program managers, program evaluators, and consumers, however, must be aware of the potential problems and biases and include an assessment of a data set's limitations in the analyses of services and the conclusions about quality. It is also critical to assess the potential for combining information from commercial and public administrative data systems so that the nature and extent of out-of-plan utilization can be assessed and added to the evaluation of the quality of care. If you give information to providers and you work with information systems with the goal of providing information in real time, then quality assurance initiatives can be transformed from an external administrative burden into a powerful tool for improving clinical practice and increasing efficiency. Geoffrey Reed American Psychological Association Public Workshop, April 18, 1996, Washington, DC ROLE OF GOVERNMENT IN QUALITY ASSURANCE Historically, the federal government's involvement in quality review and accreditation has been indirect. For example, in the area of hospital accreditation, the federal government has typically given an accreditation organization such as JCAHO deemed status. This means that the federal government makes use of the information collected by JCAHO and relies on JCAHO's judgments regarding the quality of hospitals in setting eligibility rules for reimbursement by Medicare. States also are beginning to review and update traditional regulatory and contracting practices and to develop arrangements for deemed status. For example, COA holds deemed status in 22 states that recognize the COA accreditation process in lieu of Medicaid certification, state monitoring, or licensing (COA, 1996c).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Similar sets of arrangements already are in force in other markets. For example, the American Society for Testing and Materials holds deemed status in judging the quality of building materials. Table 6.3 displays a variety of consumer protection models for comparison. Deeming can be a powerful tool, especially when the market for accreditation and measurement appears to be rather competitive. The federal or state government would grant deemed status to all organizations meeting standards of measurement and standard setting. For example, the federal or state government may decide that it will grant deemed status to any group that provides measures and standards across a specified range of domains. This would create an incentive for health plans and other organizations to develop quality measures and for accreditation organizations to measure a range of domains that extend beyond what any subset of interest groups might propose. Achieving deemed status could also require that measurements be uniformly defined and collected by third parties. Under such arrangements, the federal government's influence would stem primarily from its role as a major purchaser through Medicare, Federal Employees Health Benefits Program, CHAMPUS, and other programs. The federal government would not be regulating the quality measurement and accreditation industry, nor would it choose among competing technologies, thereby allowing innovations to continue to emerge. As states continue to re-evaluate their contracting and regulatory mechanisms, more states may develop deemed status arrangements. Under these conditions, government purchasing power would be used to promote approaches to measurement and accreditation that are consistent with concepts of efficient markets for insurance as well as consumer protection. Making use of deemed status in this manner may be particularly important in the behavioral health care arena if the market failures outlined above are significant. This discussion suggests that the interests of enrollees and consumers of health care may be underrepresented in existing measurement and accreditation processes. The federal government could also serve to enhance the significance of consumer input. First, existing governmental efforts such as SAMHSA's sponsorship of a consumer-oriented report card can be used to increase consumer input to the development of health plan rating systems. This has been done with some success under the SAMHSA report card project. A second approach would be for the government to make use of information based on consumer groups' ratings of the raters. That is, organizations such as American Association of Retired Persons, National Seniors Health Cooperative, Consumers Union, and the National Alliance for the Mentally Ill could be asked to rate accreditation and quality measurement systems. This information could be incorporated into the federal government's decision to give an accreditation organization deemed status. Again, this approach uses the federal government' s purchasing power to advance representation of the interests that the market may fail to give adequate weight.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 6.3 Selected Regulatory and Consumer Protection Models Name Establishment Duties Structure Industry Regulation Better Business Bureaus Established in 1912 Provide consumer reports on businesses, charity groups, and organizations; resolve consumer-business disputes; promote ethical and voluntary self-regulation of business Community-based, private and nonprofit; supported mostly by membership dues paid by business and professional groups; coordinated by Better Business Bureaus Council, Inc. No legal powers; dispute resolution through telephone conciliation, mediation, or nonbinding arbitration Federal Aviation Administration Air Commerce Act of May 20, 1926 Ensure the safety and efficiency of the air transportation system; maintain public confidence; regulate air navigation and air traffic control; minimize environmental impact of aviation; and conduct/support aviation research and development Operating arm of the U.S. Department of Transportation; the administrator is nominated by the President Monitors operation of the nation's air traffic control system; certifies pilots, aircraft, and airports; establishes and enforces aviation and security rules Federal Deposit Insurance Corporation Banking Act of 1933 (Glass-Steagall Act) Maintain stability and public confidence in the banking system Board of directors and a chairman; one member is Comptroller of the Currency; one is Director of Office of Thrift Supervision; three are presidential appointees Establishes criteria under which a bank is eligible for federal deposit insurance Federal Reserve System Federal Reserve Act of 1913 Conduct monetary policy; supervise and regulate banking institutions; maintain stability of financial system; protect consumers Independent government agency; Board of Governors with chair and vice-chair appointed by President; 12 regional Federal Reserve Banks; 25 branches; advisory bodies include 30-member Consumer Advisory Council Review member banks for compliance with banking regulations every 18 months on average, with poor performers reviewed more frequently and good performers reviewed every 24 months; investigate complaints; maintain national database to identify potential institutional or industrywide problems

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Federal Trade Commission Federal Trade Commission Act of 1914 Enforce federal antitrust and consumer protection laws; ensure fair and efficient operation of the market; safeguard informed choice of consumers Independent government agency; five presidentially appointed commissioners Rule-making; investigation of complaints or infractions with results of voluntary compliance (no guilt admitted but suspect practice halted), a “cease and desist” order to end the offending practice; facilitate consumer redress in civil courts Financial Accounting Standards Board Designated by the Securities and Exchange Commission (SEC) in 1973 Establish standards of financial accounting and reporting; keep standards in line with current industry practice and ensure international comparability of reporting methods; improve common understanding of information in financial reports Private, nonprofit; operates under the Financial Accounting Foundation; seven members including a chair and vice-chair assisted by Financial Accounting Standards Advisory Council Conduct a deliberative process that seeks to develop neutral standards; authority delegated by SEC Food and Drug Administration Food and Drugs Act of 1906; organized as the Food and Drug Administration in 1930 Ensure the safety of food, cosmetics, medicines, medical devices, radiation-emitting products, feed and drugs for pets and farm animals; provide for informed consumer choice through fair and open product labeling Since 1988 an official agency of the U.S. Department of Health and Human Services with a Commissioner appointed by the President; 9,000 employees located in Washington, DC and 157 offices across the country Regulation of approximately 95,000 U.S. businesses; investigations and inspections to verify manufacture and labeling; verification of producer product tests; approval of import safety; the Food and Drug Administration approves chemicals and products for use in the U.S.; enforcement capabilities include encouraging voluntary correction, recalls, court ordered recall and cessation of sales; fines and/or imprisonment National Association of Insurance Commissioners Established in 1871 Protect the interests of insurance consumers through coordination of regulations across multi-state insurers Private, nonprofit organization encompassing all insurance regulators involved in life, accident, health, commercial, and special insurance from 50 states and District of Columbia Require insurance departments to have adequate statutory and administrative authority to regulate an insurer's corporate and financial affairs through accreditation program; evaluations are conducted every 5 years; publish and

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH         disseminate consumer guides; create models for legislation, regulation, and guidelines (e.g., Quality Assessment and Improvement Model Act and Health Care Assessment and Improvement Model Act) Occupational Safety and Health Administration Occupational Safety and Health Act of 1970 Save lives, prevent injuries, and protect the health of America's workers Element of the Department of Labor under the Assistant Secretary for Occupational Safety and Health; three-person, presidentially appointed, Occupational Safety and Health Review Commission; advisory organs include National Advisory Committee on Occupational Safety and Health which includes participation by Department of Health and Human Services; over 200 regional offices nationwide Establish regulations on employee health and safety; provide consultation and assistance with interpretation and applications of regulations; undertake inspections, investigate complaints, and issue citations to ensure compliance with regulations; provide training on occupational health and safety issues; the Commission may pursue penalties including cessation of hazardous activities, fines, and/or prison terms for violations Securities and Exchange Commission Securities and Exchange Act 1934 Ensure fair competition and of provision of services; ensure fair and free access to information; protect the interests of the consumer Independent government agency; five presidentially appointed commissioners, with one serving as chair; 11 regional offices across United States Provide interpretation and guidance on regulatory compliance; engage in rule-making or modification; conduct investigations and hold hearings; decisions may include suspension or revocation of registration and censure or ban from securities associations; work with criminal authorities in matters of mutual interest SOURCES: Board of Governors of the Federal Reserve System (1994), Council of Better Business Bureaus Inc. (1996), FAA (1996), FASB (1996), FDA (1995), FDIC (1996), FTC (1996), GPO (1994), NAIC (1995, 1996a, b), OSHA (1996), and SEC (1996).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 6.4 Desirable Attributes of a Quality Assurance Program addresses overuse, underuse, and poor technical and interpersonal quality; intrudes minimally into the patient-provider relationship; is acceptable to professionals and providers; fosters improvement throughout the health care organization and system; deals with outlier practice and performance; uses both positive and negative incentives for change and improvement in performance; provides practitioners and providers with timely information to improve performance; has face validity for the public and for professionals (i.e., is understandable and relevant to patient and clinical decision-making); is scientifically rigorous; positive impact on patient outcomes can be demonstrated or inferred; can address both individual and population-based outcomes; documents improvement in quality and progress toward excellence; is easily implemented and administered; is affordable and is cost-effective; and includes patients and the public. SOURCE: IOM (1990). SUMMARY As discussed in Chapter 1, Chapter 2 and Chapter 3 of this report, quality measurement is complex and is evolving rapidly. This chapter has reviewed the existing means for quality assessment and has suggested some trends that may continue to develop in the future. A previous IOM committee evaluated quality measurement activities for Medicare and developed a list of desirable attributes for a quality assurance program (IOM, 1990, p. 49). The present committee believes that the list is still appropriate and is a fitting closing for this chapter (see Table 6.4). REFERENCES AMBHA (American Managed Behavioral Healthcare Association, Quality Improvement and Clinical Services Committee). 1995. Performance Measures for Managed Behavioral Healthcare Programs. Washington, DC: American Managed Behavioral Healthcare Association. Board of Governors of the Federal Reserve System. 1994. The Federal Reserve System: Purposes and Functions. Washington, DC: Board of Governors of the Federal Reserve System. CARF (The Rehabilitation Accreditation Commission). 1996. Standards Manual and Interpretive Guidelines for Behavioral Health. Tucson, AZ: The Rehabilitation and Accreditation Commission. CMHS (Center for Mental Health Services). 1995. MHSIP Consumer-Oriented Mental Health Report Card: Phase II Task Force. Washington, DC: Center for Mental Health Services. COA (Council on Accreditation of Services for Families and Children) . 1996a. Standards for Agency Management and Service Delivery. New York, NY: Council on Accreditation of Services for Families and Children.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH COA. 1996b. Council on Accreditation Profile. New York: Council on Accreditation of Services for Families and Children. COA. 1996c. Council on Accreditation Recognition Report. New York: Council on Accreditation of Services for Families and Children. Cody P. 1996. CMHS offers states grants to test performance indicators. Mental Health Report 20(13): 114. Council of Better Business Bureaus, Inc. 1996. The Better Business Bureaus World Wide Web Homepage. [http://www.igc.org/cbbb]. September. DHHS (U.S. Department of Health and Human Services). 1990. Healthy People 2000. Washington, DC: Public Health Service, U.S. Department of Health and Human Services . DHHS. 1992. Prevention 91/92. Washington, DC: Public Health Service, U.S. Department of Health and Human Services . DHHS. 1995. Healthy People 2000: Midcourse Review. Washington, DC: Public Health Service, U.S. Department of Health and Human Services . Digital Equipment Corporation. 1995. HMO Performance Standards. Maynard, MA: Digital Equipment Corporation. Donabedian A. 1982. Explorations in Quality Assessment and Monitoring: The Criteria and Standards of Quality. Vol. 2. Ann Arbor, MI: Health Administration Press. Ellwood PM. 1988. Outcomes management: A technology of patient experience. The New England Journal of Medicine 318(23):1549-1556. FAA (Federal Aviation Administration). 1996. The Federal Aviation Administration World Wide Web Homepage. [http://www.faa.gov]. September. FACCT (Foundation for Accountability). 1995. Guidebook for Performance Measurement Prototype. PortIand, OR: Foundation for Accountability. FASB (Financial Accounting Standards Board). 1996. The Financial Accounting Standards Board World Wide Web Homepage. [http://www.rutgers.edu/Accounting/raw/fasb/home.htm]. September. FDA (Food and Drug Administration). 1995. The Food and Drug Administration World Wide Web Homepage. [http://www.fda.gov]. September. FDIC (Federal Deposit Insurance Corporation). 1996. The Federal Deposit Insurance Corporation World Wide Web Homepage . [http://www.fdic.gov]. Septmeber. FTC (Federal Trade Commission). 1996. The Federal Trade Commission World Wide Web Homepage. [http://www.ftc.gov]. September. Garnick DW, Hendricks AM, Comstock CB. 1994. Measuring quality of care: Fundamental information from administrative datasets. International Journal for Quality in Health Care 6:163-177. GPO (U.S. Government Printing Office). 1994. United States Code. Washington, DC: U.S. Government Printing Office. HIAA (Health Insurance Association of America). 1996. Sourcebook of Health Insurance Data, 1995. Washington, DC: Health Insurance Association of America. IOM (Institute of Medicine). 1989a. Controlling Costs and Changing Patient Care? The Role of Managed Care. Washington, DC: National Academy Press. IOM. 1989b. The Future of Public Health. Washington, DC: National Academy Press. IOM. 1990. Medicare: A Strategy for Quality Assurance. Vol. 1. Washington, DC: National Academy Press. JCAHO (Joint Commission on Accreditation of Healthcare Organizations) . 1995. Accreditation Manual for Mental Health, Chemical Dependency and Mental Retardation/Developmental Disabilities Services—Standards. Vol. 1. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations. JCAHO. 1996. Comprehensive Accreditation Manual for Health Care Networks. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Mattson MR, ed. 1992. Manual of Psychiatric Quality Assurance. Washington, DC: American Psychiatric Association. NAIC (National Association of Insurance Commissioners). 1995. A Tradition of Consumer Protection. Washington, DC: National Association of Insurance Commissioners. NAIC. 1996a. Health Care Professional Credentialing Verification Model Act. Washington, DC: National Association of Insurance Commissioners, Adopted June 1996. NAIC. 1996b. Quality Assessment and Improvement Model Act. Washington, DC: National Association of Insurance Commissioners, Adopted June 1996. NCQA (National Committee for Quality Assurance). 1996a. HEDIS 3.0 Draft for Public Comment. Washington, DC: National Committee for Quality Assurance. NCQA. 1996b. Accreditation Standards For Managed Behavioral Healthcare Organizations . Washington, DC: National Committee for Quality Assurance. OSHA (Occupational Safety and Health Administration). 1996. The Occupational Safety and Health World Wide Web Homepage. [http://www.osha.gov]. September. Rodriguez AR. 1985. The CHAMPUS Psychiatric and Psychological Review Project. Psychiatric Peer review: Preclude and Promise. Washington, DC: American Psychiatric Press. Rodriguez AR. 1988. An introduction to quality assurance in mental health. In: Stricker G, Rodriguez AR, eds. Handbook of Quality Assurance in Mental Health. New York: Plenum Press. SAIC (Science Applications International Corporation). 1995. A Comparison of JCAHO and NCQA Quality Oversight Programs. National Quality Monitoring Project, Task 1b, Submitted to the Office of the Assistant Secretary of Defense, Health Affairs. Beaverton, OR: Science Applications International Corporation. SAMHSA (Substance Abuse and Mental Health Services Administration) . 1996. Mental Health Measures in Medicaid HEDIS. Washington, DC: Center for Mental Health Services, U.S. Department of Health and Human Services. SEC (Securities and Exchange Commission). 1996. The Securities and Exchange Commission World Wide Web Homepage. [http://www.sec.gov]. September. Slaven T. 1996. Personal communication to the Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care. Rehabilitation Accreditation Commission. May. Slee V. 1974. PSRO and the hospital's quality control. Annals of Internal Medicine 81:97-106. URAC (Utilization Review Accreditation Commission). 1996. National Network Accreditation Standards. Washington, DC: Utilization Review Accreditation Commission. Valdez RO. 1996. Presentation at the Public Workshop of the Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care. Washington, DC. April 18.