The extent to which an individual who needs care and services is able to receive them. Ease of access depends on several factors, including insurance coverage, availability and location of appropriate care and services, transportation, hours of operation, and cultural factors, including languages and cultural appropriateness.
An official decision made by a recognized organization that a health care plan, network, or other delivery system complies with applicable standards.
Individuals enrolling in health plans tend to select plans that will best suit their expected health care needs, and individuals with a greater chance of needing particular kinds of care will select health care plans with generous benefits for those services. Health plans do not know who those individuals are, so the plans have an incentive to strictly limit coverage and access to those services and thus avoid drawing an adverse selection of the enrolled population.
The extent to which a particular procedure, treatment, test, or service is clearly indicated, is not excessive, is adequate in quantity, and is provided in the setting best suited to a patient's or member 's needs (NCQA, 1995, p. 45).
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Glossary Access The extent to which an individual who needs care and services is able to receive them. Ease of access depends on several factors, including insurance coverage, availability and location of appropriate care and services, transportation, hours of operation, and cultural factors, including languages and cultural appropriateness. Accreditation An official decision made by a recognized organization that a health care plan, network, or other delivery system complies with applicable standards. Adverse selection Individuals enrolling in health plans tend to select plans that will best suit their expected health care needs, and individuals with a greater chance of needing particular kinds of care will select health care plans with generous benefits for those services. Health plans do not know who those individuals are, so the plans have an incentive to strictly limit coverage and access to those services and thus avoid drawing an adverse selection of the enrolled population. Appropriateness The extent to which a particular procedure, treatment, test, or service is clearly indicated, is not excessive, is adequate in quantity, and is provided in the setting best suited to a patient's or member 's needs (NCQA, 1995, p. 45).
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Autonomy A principle in biomedical ethics that refers to having respect for every individual's independence and freedom of choice. This is usually expressed as the need to obtain informed consent from an individual or his or her representatives before undertaking treatment. Behavioral health Managed care term that applies to the assessment and treatment of problems related to mental health and substance abuse. Substance abuse includes abuse of alcohol and other drugs. Benchmark For a particular indicator or performance goal, the industry measure of best performance. The benchmarking process identifies the best performance in the industry (health care or non-health care) for a particular process or outcome, determines how that performance is achieved, and applies the lessons learned to improve performance (NCQA, 1995, p. 45). Capitation A fixed rate of payment to cover a specified set of health services. The rate is usually provided on a per-member per-month basis (IOM, 1989, p. 288). Carve-out A decision to purchase separately a service that is typically a part of an indemnity or health maintenance organization plan. For example, a health maintenance organization may “carve out” the behavioral health benefit and select a specialized vendor to supply these services on a standalone basis (United HealthCare Corporation, 1994, p. 16). Consumer Any individual who does or could receive health care or services. Includes other more specialized terms, such as beneficiary, client, customer, eligible member, recipient, or patient. Co-occurring disorders Individuals who have more than one disorder, for example, a depressed person who also is an alcoholic. Usually, the term is used to refer to a combination of mental health and substance abuse problems, but it can also refer to individuals who have a behavioral health diagnosis as well as a medical diagnosis or disability. Cost-sharing The part of health expenses that are paid by the person who receives services, including deductibles and copayments. Credentialing The process of assessing and validating the qualifications of a licensed independent practitioner to provide member services in a health care network or its components. The determination is based on an evaluation of the individual's current license, education, training, experience, current competence, and ability to perform privileges requested. The
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH credentialing process is the basis for making appointments to the panel or staff of the health care network and its components. It also provides information for the process of granting clinical privileges to licensed independent practitioners (based on JCAHO, 1996, p. 406). Cultural comptence Actions that indicate an awareness and acceptance of the importance of addressing cultural factors while providing care; ability to meet the needs of clients and patients from diverse backgrounds. Deemed status A method of quality assurance in which public agencies hold an organization accountable to standards developed by, for example, a non-profit accreditation organization. For example, Health Care Financing Administration requires hospitals to conform to the Joint Commission on Accreditation of Healthcare Organizations standards to receive Medicare reimbursement. Dual diagnosis See Co-occurring disorder. Indicator A defined, measurable variable used to monitor the quality or appropriateness of an important aspect of patient care. Indicators can be activities, events, occurrences, or outcomes for which data can be collected to allow comparison with a threshold, a benchmark, or prior performance (NCQA, 1995, p. 47, from the JCAHO Managed Care Standards Manual, 1989, p. 56). Integrated delivery system System of providers and diverse organizations working collaboratively to coordinate a full range of care and services within a community. Managed behavioral health care Any of a variety of strategies to control behavioral health (i.e., mental health and substance abuse) costs while ensuring quality care and appropriate utilization. Cost-containment and quality assurance methods include the formation of preferred provider networks, gatekeeping (or precertification), case management, relapse prevention, retrospective review, claims payment, and others. In many health plans, behavioral health care is separated from care available in the rest of the health plan for the separate management of costs and quality of care (EAPA, 1996, p. 19). Managed care Arrangements for health care delivery and financing that are designed to provide appropriate, effective, and efficient health care through organized relationships with providers. Includes formal programs for ongoing quality assurance and utilization review, financial incentives for covered
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH members to use the plan's providers, and financial incentives for providers to contain costs. Outcome Results or effects achieved through a given service or procedure. Outcomes research Studies that measure the effects of care or services. Performance goals The desired level of achievement of standards of care or service. These may be expressed as desired minimum performance levels (thresholds), industry best performance (benchmarks), or the permitted variance from the standard. Performance goals usually are not static but change as performance improves and/or the standard of care is refined (NCQA, 1995, p. 47). Performance measure(s) Methods or instruments to estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality (IOM, 1990a, p. 50). Practice guidelines Systematically developed statements to standardize care and to assist practitioner and patient decisions about the appropriate health care for specific circumstances. Practice guidelines are usually developed through a process that combines scientific evidence of effectiveness with expert opinion. Practice guidelines are also referred to as clinical criteria, practice parameters, protocols, algorithms, review criteria, preferred practice patterns, and guidelines. Privileging The process of authorizing by an appropriate authority (e.g., a governing body, where one exists) in a component of a health care network or by the network itself a practitioner to provide specific patient care services in the component or the network, as appropriate, within defined limits, on the basis of an individual practitioner 's license, education, training, experience, competence, ability to perform assigned tasks, and judgment (JCAHO, 1996, p. 411). Quality assessment The measurement of the technical and interpersonal aspects of health care and the outcomes of that care (IOM,1990b, p. 45, based on IOM, 1989, p. 291). Quality assurance A systematic and objective approach to improving the quality and appropriateness of medical care and other services. Includes a formal set of activities to review, assess, and monitor care and to ensure that identified problems are addressed appropriately.
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Quality improvement A set of techniques for continuous study and improvement of the processes of delivering health care services and products to meet the needs and expectations of the customers of those services and products. It has three basic elements: customer knowledge, a focus on processes of health care delivery, and statistical approaches that aim to reduce variations in those processes (IOM, 1990b, p. 46). Quality of care The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM, 1990b, p. 4). NOTE: Adopted by National Committee for Quality Assurance and Joint Commission on Accreditation of Healthcare Organizations. Recovery A term used by some individuals and groups to refer to the process of making a commitment to change personal behaviors in order to overcome addiction. Thus, an individual who has chosen to make changes is “in recovery.” Report card on health care An emerging tool that can be used by policy makers and health health care purchasers, such as employers, government bodies, employer coalitions, and consumers, to compare and understand the actual performance of health plans. The tool provides health plan performance data in major areas of accountability, such as health care quality and utilization, consumer satisfaction, administrative efficiencies and financial stability, and cost control (United HealthCare Corporation, 1994, p. 64). Risk sharing The process of establishing financial arrangements that share the financial risk of providing care among providers, payers, and those who use the services. Standard(s) Authoritative statements of (1) minimum level of acceptable performance or results, (2) excellent levels of performance or results, or (3) the range of acceptable performance or results (IOM, 1990a). Utilization The extent to which eligible individuals use a program or receive a service or group of services over a specified period of time. Utilization management A set of techniques used by or on behalf of purchasers of health benefits to manage health care costs by influencing the decisions about patient care made by providers, payers, and patients themselves. Includes techniques such as prior authorization, concurrent review, retrospective review, and case management.
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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Utilization review A formal assessment of the medical necessity, efficiency, or appropriateness of health care services and treatment plans on a prospective, concurrent, or retrospective basis (United HealthCare Corporation, 1994, p. 74). REFERENCES EAPA (Employee Assistance Professional Association). 1995. Glossary of Employee Assistance Terminology. Arlington, VA: Employee Assistance Professional Association, Inc. IOM (Institute of Medicine) . 1989. Controlling Costs and Changing Patient Care: The Role of Utilization Management. Washington, DC: National Academy Press. IOM. 1990a. Clinical Practice Guidelines: Directions for a New Program Washington, DC: National Academy Press. IOM. 1990b. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press. JCAHO (Joint Commission on Accreditation of Healthcare Organizations) . 1989. Managed Care Standards Manual. Chicago, IL: Joint Commission on Accreditation of Healthcare Organizations. JCAHO. 1996. 1996 Comprehensive Accreditation Manual for Health Care Networks. Chicago, IL: Joint Commission on Accreditation of Healthcare Organizations. NCQA. (National Committee for Quality Assurance) . 1995. Standards for Accreditation, 1995. Washington, DC: National Committee for Quality Assurance. United HealthCare Corporation. 1994. The Managed Care Resource: The Language of Managed Health Care and Organized Health Care Systems. Minneapolis, MN: United HealthCare Corporation.