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Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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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).

Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

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

Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

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

Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

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.

Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

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.

Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×

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.

Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×
Page 256
Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Page 257
Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×
Page 258
Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
×
Page 259
Suggested Citation:"GLOSSARY." Institute of Medicine. 1997. Managing Managed Care: Quality Improvement in Behavioral Health. Washington, DC: The National Academies Press. doi: 10.17226/5477.
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Managing Managed Care: Quality Improvement in Behavioral Health Get This Book
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Managed care has produced dramatic changes in the treatment of mental health and substance abuse problems, known as behavioral health. Managing Managed Care offers an urgently needed assessment of managed care for behavioral health and a framework for purchasing, delivering, and ensuring the quality of behavioral health care. It presents the first objective analysis of the powerful multimillion-dollar accreditation industry and the key accrediting organizations.

Managing Managed Care draws evidence-based conclusions about the effectiveness of behavioral health treatments and makes recommendations that address consumer protections, quality improvements, structure and financing, roles of public and private participants, inclusion of special populations, and ethical issues.

The volume discusses trends in managed behavioral health care, highlighting the emerging role of the purchaser. The committee explores problems of overlap and fragmentation in the delivery of behavioral health care and discusses the issue of access, a special concern when private systems are restricted and public systems overburdened.

Highly applicable to the larger health care system, this volume will be of particular interest to all stakeholders in behavioral health—federal and state policymakers, public and private purchasers, health care providers and administrators, consumers and consumer advocates, accrediting organizations, and health services researchers.

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