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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 8 Findings and Recommendations Managed care is increasingly being used throughout the health care system, and the variability in approaches to managed care is also increasing. Managed care methods are growing at a faster rate in the behavioral health care sector than in the rest of the health care system because of their demonstrated ability to control costs in private health plans and because states are turning to managed care as a strategy to control Medicaid costs. Furthermore, because of this rate of change and because of the unique structure of mental health and substance abuse care (e.g., the existence of substantial publicly paid systems at the state and local levels), ensuring consumer protection and quality improvement are important challenges. The increased use of managed care approaches in behavioral health care presents both opportunities and risks. For example, the use of case management to coordinate care for individuals with complex conditions and conditions that are costly to treat can improve care and control costs, making it more feasible to improve insurance coverage and to integrate private and public systems. Conversely, managed care approaches that emphasize cost control over quality of care can reduce access to care and can shift the costs of care for needier individuals to an overburdened public system. Many interested parties are using a variety of methods to protect consumers and improve the quality of care in this environment of rapid change. The charge and focus of this committee are on managed care, although the committee recognizes that other issues such as licensure of practitioners and state inspection and certification of provider agencies play critical roles in consumer protection. Furthermore, in its focus on managed care, the committee has been particularly concerned with two prominent strategies: the accreditation of managed care entities
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH and the use of performance measurement systems. At the same time, it has considered complementary strategies that can aid in consumer protection and quality improvement, such as consumer choice of health plans and better integration of research and practice. This comprehensive approach is required, in the committee's view, given the interrelated, significant, and complex changes that are under way and the vulnerability of individuals who suffer from serious mental illness and addictions to alcohol and other drugs. The committee believes that there is increasing evidence that treatment for mental health and substance abuse problems is effective and that its effectiveness is generally comparable to that of treatment provided in other areas of medicine. The committee also believes that robust steps to address consumer protection and quality improvements are essential, particularly through improved accreditation and performance measurement systems. This chapter sets out the committee's recommendations in 12 areas. Each set of recommendations is preceded by the findings that led the committee to make the recommendations. In many cases, the findings build on cross-cutting themes from testimony, research, and the committee's deliberations. 1. STRUCTURE AND FINANCING Findings Historically, the structure and financing of treatment for mental health and substance abuse problems have been inherently problematic. Insurance coverage for mental health and substance abuse care has been limited and frequently has not covered the prolonged treatment that consumers and families need to address complex problems. The separate publicly-financed health care system creates incentives for the private sector to limit benefits and thus to undermine the basic purpose of insurance; that is, to provide protection for large losses. Costly care is often shifted to the underfinanced public system, a process that is sometimes called “dumping.” Traditionally, the health care system inhibits access to care and tolerates poor quality of care, and thus contributes to poor outcomes. The problems of reduced access and increased cost shifting may be aggravated by the use of managed care approaches that focus exclusively on reducing costs. High-quality managed care, however, can provide tools to control costs in an integrated system. For example, case management for high-cost treatment can improve access to appropriate treatment while controlling costs. Existing measures and indicators are inadequate for use as evidence of dumping, skimming, and cost-shifting. Historically, the categorical and fragmented nature of public funding has contributed to fragmentation in service delivery.
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH A recent trend is to combine Medicaid funds with other state and local public funds in the financing of public systems. The fundamental problems in mental health and substance abuse care cannot be fully addressed without changing the structure and financing of the system and attending to the problem of the separate public and private sectors of care. Recommendations 1.1 The reform of systems of care financed by states and counties must: (1) recognize current aspects of private health care in those states and counties and (2) consider the design and development of mechanisms to inhibit cost-shifting. 1.2 Payment arrangements that reduce incentives to underserve individuals with behavioral health conditions should be encouraged. 1.3 The reform of state and local systems through the use of managed care should incorporate a recognition of and responsiveness to the unique needs of consumers served by public systems. 1.4 Accreditation organizations, when appropriate, and purchasers should develop criteria and guidelines that: (1) recognize and measure dumping, skimming, and cost-shifting; and (2) specify rewards for organizations, groups, and individuals that provide appropriate care and penalties for those that do not. 1.5 Purchasers should ensure continuity of care for consumers when managed care contracts are awarded to different provider organizations. 2. ACCREDITATION Findings The wide array of consumer and quality protections includes accreditation, performance measurement, clinical practice guidelines, state licensure, and contract requirements. Some of these functions overlap. Accreditation of managed care plans by independent national bodies is an important and powerful tool of consumer protection and quality improvement in health care and behavioral health care. Accreditation of service delivery organizations, such as hospitals, is well developed, but accreditation of managed care plans is in its infancy. In the field of managed behavioral health care, accreditation alone is not sufficient to guarantee high-quality care. Currently, multiple competing organizations perform measurement, reporting, and accreditation functions in the health and behavioral health care sectors. In the behavioral health care area, the Rehabilitation Accreditation Commission (CARF), Council on Accreditation of Services for Families and Children (COA), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), National Committee for Quality Assurance (NCQA), and Utilization
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Review Accreditation Commission (URAC) all play roles in accrediting managed care plans that cover mental health and substance abuse care. The American Managed Behavioral Healthcare Association, NCQA, the Substance Abuse and Mental Health Services Administration (SAMHSA), and a number of corporate buyers (e.g., Digital Equipment Corporation) have also developed performance rating systems. Accreditation organizations compete for accreditation business on the basis of their credibility with payers, providers, and consumers. Benefits consultants and other consultants are advising corporate purchasers and state agencies on procurement, contracting, and other aspects of accountability. This is a significant new industry. Data collection is an intricate part of the assessment of quality of care. Many of the data currently collected are internal, not validated by external sources, and may not be relevant to outcomes of care. Accreditation tends to focus on measures of the structure and process of care rather than on measures of clinical outcomes. However, examples of movement in the direction of outcome measurement can be found, such as consumer satisfaction surveys and measures of clinical appropriateness. Variability exists in utilization review (a formal assessment of the necessity for services and their appropriateness and efficiency), which can be done on a prospective (precertification), concurrent, or retrospective basis. In public systems of mental health and substance abuse care, uninsured and publicly insured individuals can often access a greater selection and intensity of benefits for behavioral health care than are available to individuals with private insurance. Federal and state government agencies sometimes require accreditation and specify which accreditation organization's standards will be accepted. This process is known as granting an accreditation organization “deemed status.” Thus, the organization is “deemed” to act in the public interest. Deeming is not done extensively in health care but is common in other sectors, such as in the construction industry. Quality improvement methods have great potential but are still in preliminary stages for mental health and substance abuse services. Existing behavioral health performance measurement systems have used different strategies in their development, with varying degrees of consumer involvement. Recommendations Monitoring Quality of Care 2.1 Public and private purchasers, consumers, providers, practitioners, behavioral health care plans, and accreditation organizations should continue to monitor and assess the quality of care in the following ways:
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 2.1.1 Quality improvement should be a priority, and principles and methods of improving quality should be adopted. 2.1.2 Accreditation and review processes must be reliable and valid and must be continuously reviewed and improved. 2.1.3 Domains relevant to the effective treatment and prevention of behavioral health problems must be emphasized in accreditation processes. These include practitioner training, consumer education, improvements in consumer self-care, and the presence of a continuum of services, including wraparound services such as housing assistance, child care, and transportation. 2.1.4 Accreditation processes must focus on areas of managed care in which there may be a risk of quality problems: (1) variability in utilization review; (2) inconsistent or inappropriate precertification processes; (3) vulnerable groups and those who are unfamiliar with managed care processes; and (4) conditions that occur frequently and are treated by many practitioners, giving opportunities for variation in treatment practices. 2.1.5 Performance measures must be relevant to treatment processes and outcomes. 2.1.6 Data must have demonstrable integrity. External, independent audits can help to validate data quality. 2.1.7 Stakeholder consensus and consumer satisfaction measures must be included in the tools used to monitor quality of care. 2.1.8 Outcomes measures should increasingly be based on evidence from research. Contracting 2.2 Quality of care should be clearly addressed in contracts between purchasers and providers. 2.2.1 When plans contract or subcontract for the management and delivery of behavioral health care services (e.g., health maintenance organizations contracting with carved-out managed behavioral health care firms), purchasers can benefit from independent audits of the contractor regarding the level of adherence to prespecified standards of performance with respect to quality. 2.2.2 Purchasers can benefit from carefully constructed contract language to ensure the quality, accessibility, and effectiveness of behavioral health plans. Contracts should also specify the ways in which the quality and effectiveness standards will be monitored and enforced, including conditions for applying positive incentives for meeting or exceeding the standards and penalties for substandard performance. Role of the Federal Government 2.3 The federal government should play a role in consumer protection in managed care by:
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 2.3.1 Promoting the improvement and use of performance measures for managed care. 2.3.2 Monitoring and studying the use and effectiveness of quality assurance, accreditation, performance measures, and outcomes measurements. 2.3.3 Establishing minimum standards for accreditation organizations to achieve deemed status (i.e., when the government, in its role as purchaser of managed care services, accepts accreditation as a measure of adequate quality and consumer protection). Role of State Governments 2.4 The role of state governments in consumer protection should include the following: 2.4.1 Support the development of consumer protection standards for managed behavioral health care by state mental health and substance abuse agencies, state Medicaid agencies, state insurance departments, state licensing boards, state hospitals, and state child welfare agencies. State consumer groups, such as the chapters of the National Mental Health Association (NMHA), National Depressive and Manic Depressive Association (NDMDA), National Association for Research on Schizophrenia and Depression (NARSD), and National Alliance for the Mentally Ill (NAMI), should be included in the development of standards. 2.4.2 Maintain the minimum necessary regulatory standards, including the use of accreditation, to assure consumer protection while encouraging innovations in the delivery of care. 2.4.3 Consider offering deemed status to specific accreditation organizations that meet state-defined standards for quality of managed behavioral health care services. Roles of All Levels of Government 2.5 Both federal and state governments should: 2.5.1 Encourage the development of report cards or other similar materials to help inform consumers and families about specific plans and the quality of care. 2.5.2 Include all stakeholders (accreditation organizations, employers, state agencies, consumers, families, providers, and practitioners) in the development, implementation, and use of standards. Provider Inclusion 2.6 Because managed care methods are increasingly applied to public systems, accreditation bodies and managed care plans should evaluate the inclusion
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH of a variety of types of practitioners, including substance abuse counselors and mental health workers, in provider panels; collect information on practitioner effectiveness; and remove any practitioners from networks only for performance reasons (e.g., poor outcomes and poor consumer satisfaction). 2.6.1 The Substance Abuse and Mental Health Services Administration (SAMHSA), Agency for Health Care Policy and Research (AHCPR), Health Resources and Services Administration (HRSA), and National Institutes of Health (NIH) (National Institute on Alcohol Abuse and Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]) should cosponsor research to evaluate the components of treatment that are most effective in providing behavioral health care, including strategies used by psychiatrists, psychologists, social workers, counselors, and primary care practitioners. 2.6.2 The Substance Abuse and Mental Health Services Administration (SAMHSA), Agency for Health Care Policy and Research (AHCPR), Health Resources and Services Administration (HRSA), and National Institutes of Health (NIH) (National Institute on Alcohol Abuse and Alcoholism [NIAAA], National Institute of Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]) should cosponsor research to evaluate the cost-effectiveness of using different practitioner types to provide behavioral health care, including individual psychiatrists, psychologists, social workers, counselors, primary care practitioners, and teams with different practitioner combinations. 3. CONSUMER INVOLVEMENT Findings Individuals who have been treated for severe mental health problems are most often referred to as “consumers,” both by the individuals themselves and by the organizations that represent them. Consumers and families strongly desire to participate fully in decision-making in treatment, setting behavioral health care standards, and developing performance measures. Public behavioral health service systems make use of self-help groups, consumer-operated services, and experientially trained counselors (e.g., mental health workers and substance abuse counselors) as service providers. These practices are both valuable and highly valued in these systems because they help to support consumers and, for example, to assist with medication compliance. Quality measures are being developed by organizations with various degrees of involvement by consumers and consumer groups. Among consumers, the report card developed by the Center for Mental Health Services (CMHS) is viewed as having the most consumer involvement.
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Recommendations 3.1 Health care purchasers must be responsive to consumers and families and should develop means of ensuring their meaningful participation in treatment decisions, measurement of satisfaction, and measurement of treatment effectiveness. 3.2 Accreditation bodies should evaluate the extent of inclusion of consumers and families in treatment decisions and program planning. 3.3 The activities that are used to develop and review quality measures should include all stakeholders, including consumers, families, practitioners, and researchers. 4. CULTURAL COMPETENCE Findings Racial and ethnic minorities frequently lack access to culturally appropriate care. In the effort to create smaller and more efficient provider networks, there is a risk of eliminating providers and groups who have special expertise with different cultures and different healing practices (e.g., Afrocentric counseling and Spanish-speaking services, sweat lodges for Native Americans, and American Sign Language services for individuals who are deaf). Often, the reason given for exclusion of cultural practices is that accepted evidence of effectiveness does not exist. The committee observes, however, that controlled trials or other outcomes assessments have not been done for many, if not most, medical treatments. Recommendations 4.1 Health plans and programs should be responsive to community demographics and to the cultural needs of the populations that they serve. 4.2 Practitioners of alternative and innovative treatments without an accepted research base should not arbitrarily be excluded from health plans. If these treatments are used, their effectiveness should be studied so that standards of quality improvement can be developed. 4.3 Health plans should have an explicit mechanism for evaluating new and innovative techniques and types of practitioners.
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 5. SPECIAL POPULATIONS Findings People with disabilities, such as individuals who are deaf, hard of hearing, or blind, who use wheelchairs, or who have had traumatic brain injury, frequently lack access to care that is appropriate. Individuals who have child care responsibilities, most of whom are women, often have barriers to participating in treatment. Individuals who have co-occurring substance abuse and mental health problems need coordinated care to maintain their recovery. Recommendations 5.1 Research is needed to identify incentives for plans to serve vulnerable populations. The Substance Abuse and Mental Health Services Administration (SAMHSA) should work with other federal agencies to develop a plan to conduct such research. 5.2 Plans that serve distinct populations should measure and evaluate the needs of those groups through reviews of research literature, consumer surveys, and other appropriate mechanisms. 5.3 All plans should meet the same core standards. Supplemental standards can be developed for special populations, whether they are in stand-alone programs or in mainstream plans, for example, for a child of an employed person with family coverage. 6. RESEARCH Findings Health services research stimulates collaboration among providers, researchers, and managed care organizations and can facilitate the development of valid and useful measures of treatment processes and outcomes through such collaborations. Research and practice interact too infrequently, and few incentives exist for collaboration among researchers, practitioners, and policymakers. Outcomes research is often unresponsive to emerging problems in clinical practice and also rarely provides direction for accreditation and quality improvement efforts. The federal government plays a key role in the support of health services research and thus in the development of the necessary knowledge base for improving the quality of behavioral health care.
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Recommendations 6.1 The committee recommends continued development of collaborative health services research in substance abuse and mental health, and encourages the Agency for Health Care Policy and Research (AHCPR), Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH) (National Institute on Alcohol Abuse and Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], and the National Institute of Mental Health [NIMH]), and Substance Abuse and Mental Health Services Administration (SAMHSA) to maintain, to evaluate, and, where necessary, to expand programs and initiatives that support collaborative health services research. 6.2 The agencies mentioned above should support further research on the effectiveness of different treatment strategies for a variety of practitioner types and for consumers with different needs. 6.3 Researchers should become more involved in studies carried out in managed care organizations and community-based settings and in other clinical outcomes research used to develop standards and performance measures. 7. WORKPLACE Findings Society and individual workers need safe and supportive work environments. The federal government has responded through the passage of legislation (e.g., the Family and Medical Leave Act and the Americans with Disabilities Act) and regulations concerning safety and other standards. The workplace environment provides an excellent arena in which to address behavioral health problems. Recommendations 7.1 Employers should investigate the benefits of wellness activities, employee assistance programs, and health risk reduction initiatives that enhance prevention, early intervention, access, and treatment adherence for health and behavioral health problems. 7.2 The Substance Abuse and Mental Health Services Administration (SAMHSA) should identify models of successful behavioral health programs in the workplace and increase public awareness of these models.
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 8. WRAPAROUND SERVICES Findings For long-term recovery to be sustained, the social aspects of consumers ' lives must be addressed as part of the behavioral health care provided. Medical and managed care models often do not take these rehabilitative and support services into account. In the substance abuse field, these are known as wraparound services and in the mental health field they are also known as enabling services. Some symptoms of mental illness and substance abuse—such as severe anxiety and depression, active psychosis, and substance abuse withdrawal—interfere with social judgment and functioning. Recommendations 8.1 Further research is needed to prioritize the essential components of a treatment regimen that can address adequately the complex behavioral aspects of recovery from alcoholism and other drug addictions. 8.2 To maximize full functioning for individuals with severe and persistent mental illness, and to optimize conditions supporting recovery for individuals with chronic substance abuse problems, wraparound services such as social welfare, housing, vocational, and rehabilitative services should be available and should be coordinated. 8.3 For children and adolescents with severe emotional disturbances, educational and home environment-family support services should be coordinated and integrated with mental health care. 8.4 Accreditation systems must address the social and rehabilitative aspects as well as the medical aspects of comprehensive treatment for addiction and severe and persistent mental illness. 9. CHILDREN AND ADOLESCENTS Findings Services for children and adolescents are fragmented across many different agencies, such as mental health, child abuse and neglect, and juvenile justice. Many treatment models focus on a high-risk child or adolescent and do not involve the family or other caretakers. Developmentally appropriate, comprehensive models for intervention and treatment for adolescents are not well-defined or applied in the current public and private systems.
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH The needs of many high-risk youth are unmet because traditional systems do not focus on this population. Prevention and treatment programs for mental health and substance abuse problems are not adequately linked. Recommendations 9.1 The Substance Abuse and Mental Health Services Administration (SAMHSA), National Institutes of Health (NIH) (National Institute on Alcoholism and Alcohol Abuse [NIAAA], National Institute on Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]), and the Health Resources and Services Administration (HRSA) should identify exemplary models of coordinated systems of care for children and adolescents. 9.2 The Substance Abuse and Mental Health Services Administration (SAMHSA), National Institutes of Health (NIH) (National Institute on Alcoholism and Alcohol Abuse [NIAAA], National Institute on Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]), and the Health Research and Services Administration (HRSA) should identify exemplary models of linking behavioral health treatment and prevention programs for children and adolescents to address suicide, substance abuse, and other areas. 9.3 The Substance Abuse and Mental Health Services Administration (SAMHSA), National Institutes of Health (NIH) (National Institute on Alcoholism and Alcohol Abuse [NIAAA], National Institute on Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]), and the Health Resources and Services Administration (HRSA) should support research to identify the elements of developmentally appropriate treatment that should be available to adolescents who are abusing alcohol or drugs or who have mental health problems. 9.4 The public and private systems must make efforts to develop service capabilities to meet the needs of adolescents who are abusing alcohol or drugs and adolescents who have mental health problems. 10. CLINICAL PRACTICE GUIDELINES Findings Practice guidelines are developed by professional organizations, managed care organizations, and other groups. The development of guidelines is not always systematic, and guidelines are not always linked to empirical findings. Little or no information is available on successful strategies for implementing guidelines. Accreditation tends to measure whether plans or managed care organizations have guidelines in place and does not address the quality of the guidelines
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH used by plans or organizations, or the extent to which care is actually monitored and changed according to those guidelines. Recommendations 10.1 The development of clinical practice guidelines should be linked to outcomes research, performance standards, and accreditation. 10.2 The Agency for Health Care Policy and Research (AHCPR), Substance Abuse and Mental Health Services Administration (SAMHSA), and other agencies and organizations that develop guidelines should sponsor additional research that examines the successful implementation of guidelines and identifies successful implementation models. 10.3 Practitioners and consumers should be included in the development of practice guidelines. 11. PRIMARY CARE Findings Many individuals (10 to 20 percent of the population) consult primary care physicians for behavioral health problems. Responsibility for behavioral health care is frequently divided between primary and specialty settings, which are not well integrated, and this division of responsibility results in poor coordination of care. Few guidelines exist for behavioral health treatment in primary care. Some individuals may be treated more successfully in specialty settings than in primary care settings. Recommendations 11.1 This committee endorses the view of the Institute of Medicine (IOM) Committee on the Future of Primary Care, which recommended “the reduction of financial and organizational disincentives for the expanded role of primary care in the provision of mental health services” and “the development and evaluation of collaborative care models that integrate primary care and mental health services more effectively. These models should involve both primary care clinicians and mental health professionals” (IOM, 1996, p. 137). 11.2 This committee recommends that the above recommendation include alcohol and other drug abuse problems as a defined area of expertise.
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 12. ETHICAL CONCERNS Findings The field of health care ethics embodies ethical principles that address risks in the areas of autonomy, access, informed consent, practitioner-patient relationships, and confidentiality. Ethical challenges and problems exist in both the traditional fee-for-service system and in the rapidly developing managed care system, although the incentives, risks, and oversight strategies differ in the two settings. Cultural competence and sensitivity are ethical issues. Recommendations 12.1 Managed care organizations should be able to demonstrate that they recognize and have concern for the ethical risks created by managed care systems. Additionally, they should substantiate the use of safeguards that protect and maintain ethical standards and practices. These would include the following: a clear description of a plan, its benefits, and grievance procedures, accessible and responsive grievance, complaint, and appeals procedures, effective strategies to maintain confidentiality while meeting the needs of practitioners to coordinate care, culturally appropriate and gender-specific service practitioners in the network, consumer surveys and measures of consumer satisfaction, consumer representation on policy development and grievance resolution, continuous improvement protocols to promote better outcomes, and no contractual or other limitations for physicians and other practitioners concerning the discussion of clinically appropriate treatment options with patients and families. 12.2 A careful review of ethical issues in various settings, for example, managed care organizations, networks, and fee-for-service settings, is needed. The Substance Abuse and Mental Health Services Administration (SAMHSA), Health Care Financing Agency (HCFA), and Agency for Health Care Policy and Research (AHCPR) should develop a plan to examine ethical issues. REFERENCE IOM (Institute of Medicine). 1996. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press.
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