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2

Trends in Managed Care

Market forces are creating dramatic shifts in the structure and conduct of business in the health care delivery system. Employers, government agencies, and other purchasers of health care have become increasingly aggressive in demanding competitive prices from suppliers of health care services. The response to the new strategies in purchasing health care has been an acceleration in the growth of managed care organizations.

Managed care imposes organization, controls, quality measurement, and accountability on the delivery of health care to achieve the purchaser's goals for access to care, quality of care, effectiveness of care, and cost of care (Goldstein, 1989; Mechanic et al., 1995; Miller and Luft, 1994; Wells et al., 1995). The introduction and expansion of managed care strategies have altered the organization of general health care (e.g., Shortell et al., 1994) and have begun to influence the delivery of privately and publicly reimbursed mental health and substance abuse treatment. Because behavioral health care takes place in primary and specialty settings and because there is a distinct publicly paid and managed system for the delivery of behavioral health care, the introduction of managed care in one setting can change the relationship to health care in other settings.

Potential problems of the quality of and access to behavioral health care under the managed care system have long been concerns of policymakers. Demonstration projects in Medicaid within the private insurance industry provide some evidence of the impacts of managed care arrangements on utilization and quality (Mechanic et al., 1995). The evidence supports the ability of health maintenance organizations (HMOs) to control the costs of behavioral health care (Frank et al., 1995). There is also mounting evidence that specialty behavioral health compa-



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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 2 Trends in Managed Care Market forces are creating dramatic shifts in the structure and conduct of business in the health care delivery system. Employers, government agencies, and other purchasers of health care have become increasingly aggressive in demanding competitive prices from suppliers of health care services. The response to the new strategies in purchasing health care has been an acceleration in the growth of managed care organizations. Managed care imposes organization, controls, quality measurement, and accountability on the delivery of health care to achieve the purchaser's goals for access to care, quality of care, effectiveness of care, and cost of care (Goldstein, 1989; Mechanic et al., 1995; Miller and Luft, 1994; Wells et al., 1995). The introduction and expansion of managed care strategies have altered the organization of general health care (e.g., Shortell et al., 1994) and have begun to influence the delivery of privately and publicly reimbursed mental health and substance abuse treatment. Because behavioral health care takes place in primary and specialty settings and because there is a distinct publicly paid and managed system for the delivery of behavioral health care, the introduction of managed care in one setting can change the relationship to health care in other settings. Potential problems of the quality of and access to behavioral health care under the managed care system have long been concerns of policymakers. Demonstration projects in Medicaid within the private insurance industry provide some evidence of the impacts of managed care arrangements on utilization and quality (Mechanic et al., 1995). The evidence supports the ability of health maintenance organizations (HMOs) to control the costs of behavioral health care (Frank et al., 1995). There is also mounting evidence that specialty behavioral health compa-

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH nies and other approaches to managed care lower costs compared with the costs of indemnity insurance plans (e.g., Essock and Goldman, 1995; Frank et al., 1995). This chapter discusses some of the major trends in managed care and their implications for behavioral health care: (1) the increasing rate of growth of managed care, (2) the rapid expansion in the use of managed care systems by public-sector populations, (3) the role of purchasers in managing costs, and (4) the recognition of quality assurance and quality improvement mechanisms as tools for purchasers in making informed decisions. The chapter provides an overview of different quality monitoring mechanisms, including accreditation, quality improvement, performance measurement, licensing, and other credentialing activities, and discusses consumer protections, including confidentiality. Although the responsibility for quality is diffuse, the committee believes that quality assurance and accreditation can be used as tools to help purchasers of care receive the most effective care at the lowest appropriate price. THE CHANGING HEALTH CARE SYSTEM Managed Care Conventional insurance, also called indemnity or fee-for-service insurance, places few restrictions on the choice of practitioners whose services are covered. Practitioners are reimbursed on the basis of the numbers and types of services that they provide, which produces unintended consequences: an incentive for practitioners to provide more services and an incentive for patients to seek more services because they are paid for by a third party. Costs under indemnity coverage are typically controlled by higher copayments, strict limits on services, and lifetime limits on aggregate coverage. In contrast, managed care imposes limitations on utilization by specifying which practitioners and which services are covered, and often also the number of allowable visits. Managed care comes in many forms and new structures continue to develop, making generalizations difficult. However, managed care plans have the following characteristics in common (HIAA, 1996): they make arrangements with selected practitioners to furnish a specific set of health care services to enrollees; they have explicit criteria and standards for the selection of practitioners; they have formal programs for ongoing quality assurance, quality improvement, and utilization review; and they have financial incentives for members to use the practitioners and procedures that are covered by the plan. As discussed throughout this report, enrollment in managed care plans con-

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH tinues to increase in both the private and public sectors (see Table 1.2 and Table 1.4 in Chapter 1). Although many think of managed care as a recent phenomenon, it began in the 1930s with the first prepaid group practices, forerunners of what are now known as HMOs. Early practitioners of managed care believed that it was a way to improve quality and coordination of care, as well as to increase emphasis on prevention (Starr, 1982). Since the mid-1980s, managed care has gone through three major phases (CSAT, 1994). The first phase focused on managing access to health care, primarily using utilization review and administrative barriers such as pre-admission certification. The second phase focused on managing benefits, and in addition to utilization review, added fee-for-service provider networks, selective contracting, and treatment planning. In the third phase, the focus is on managing care, with a shift from utilization review to utilization management and emphasis on appropriateness of care. The fourth phase, which has begun in the last few years, is outcomes management in an integrated services system with a full continuum of treatment services. Many structures of managed care have evolved. As indicated in Table 2.1, the types of HMOs include staff model, group model, network model, independent practice association (IPA), and mixed model HMOs. HMOs rely on capitation (a prepaid, fixed amount, usually per enrolled member per month) and other incentives to control costs, including the use of nonphysician practitioners and lower-intensity treatments. The group practice structure of HMOs allows better coordination between primary care and specialty practitioners, because, for example, practitioners are co-located and medical records are more easily shared. Another prominent type of managed care plan is the preferred provider organization (PPO), which offers more flexibility in choosing practitioners than HMOs but which still offers incentives for seeing selected practitioners. PPOs are networks of practitioners that are most often organized by insurers, managed care organizations, or groups of practitioners. The networks contract with groups of practitioners who agree to provide services for a negotiated fee schedule (HIAA, 1996). Individuals who want to see a practitioner who is outside of the network can do so, but there is a financial penalty. Point-of-service plans (POS) combine features of HMOs and PPOs. They use a network of selected practitioners who are reimbursed by either capitation or fee-for-service. Individuals choose a primary care practitioner who controls access to specialists, and copayments for seeing practitioners within the plan are low. When individuals see practitioners outside the plan, they pay higher deductibles and copayments (HIAA, 1996). Currently, the feature most associated with managed care is cost containment. Compared with indemnity plans, managed care plans have significantly lower rates of utilization of inpatient hospitalization, lower rates of utilization of more expensive and discretionary tests, increased utilization of preventive services, and mixed results on quality as measured through outcomes (Miller and

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 2.1 Types of Managed Care Organizations Type of Organization Organization Description Accreditation Bodies Relevant Regulatory Bodies Health Maintenance Organization (HMO) Staff model (practitioners are salaried employees of the HMO) Group model (HMO pays a group of practitioners a negotiated, per capita rate, which is then distributed among the individuals) Network model (practitioners work out of their own offices under contract with the HMO) Individual Practice Association (IPA) model (practitioners continue individual or group practice with compensation by capitation and/or fee-for-service [FFS] plans) Mixed model (combination of two or more of the above) An organized system of health care that provides a comprehensive range of health care services to a voluntarily enrolled population in a geographic area on a primarily prepaid and fixed periodic basis National Committee for Quality Assurance (NCQA) Accreditation Association for Ambulatory Health Care (AAAHC) Utilization Review Accreditation Commission (URAC) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Federal licensing agencies, state insurance commissions, state departments of mental health, and state departments of public health Preferred Provider Organization (PPO) A network discount, FFS provider arrangement with incentives to stay inside the network; allows services outside of the PPO network at an increased copayment and/or deductible; has structured quality and utilization management NCQA JCAHO URAC (after its purchase of the American Accreditation Program, Inc.) State insurance departments

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Point-of-Service (POS) An organized system of health care provided by an HMO model with the option of the delivery of services outside of the network at a higher copayment or deductible NCQA JCAHO URAC State insurance departments Management Services Organization (MSO) An organization that provides practice management, administration, and support services to individual physicians or group practices JCAHO State insurance departments Employee Assistance Programs (EAP) Programs to assist employees, their family members, and employers in finding solutions for workplace and personal problems The Employee Assistance Professional Association has a certification program (EAPA) None Managed Behavioral Health Care Organizations (MBHO) An organized system of behavioral health care delivery usually to defined population or members of HMOs, PPOs, and other managed care structures; also known as a carve-out Council on Accreditation of Services for Families and Children (COA) Rehabilitation Accreditation Commission (CARF) JCAHO NCQA URAC State insurance departments State public health departments State mental health departments SOURCES: EAPA (1995), JCAHO (1996), NCQA (1995), and United HealthCareCorporation (1994).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Luft, 1994). Because of the demonstrations of cost savings, managed care has become more attractive to public agencies; for example, in 1995, 32 percent of Medicaid recipients were enrolled in managed care plans (HCFA, 1996). Another feature of managed care is the development of specialty networks or “carve-outs” for mental health and substance abuse, cancer, vision, dental, and other types of care. Managed behavioral health care companies have been among the fastest growing in the managed care sector. Currently, 88 percent of the individuals in managed care and a total of 125 million individuals are enrolled in a variety of managed behavioral health care products ranging from utilization review only to capitated carve-outs. Carve-out vendors may be specialized units within larger managed care organizations or they may be independent companies. Staff model HMOs have traditionally provided mental health and substance abuse care by their own staffs, now called a “carved-in” arrangement. In the area of mental health, HMOs have typically been found to spend only 3 to 5 percent of their budgets on mental health, whereas spending for mental health care is 10 percent of the overall budget for the health care system in general (Schadle and Christianson, 1988). These findings have led to concerns among consumers and family members about undertreatment, especially for individuals with serious and persistent mental illness (Flynn et al., 1994; Gerson, 1994). Another concern relates to adverse or biased selection, referring to the tendency for managed care organizations to enroll “good risks” or healthy individuals (Frank et al., 1995). Increasingly, advocates look to managed behavioral health care to improve the quality of care for individuals with behavioral health problems, and because increasing numbers of public-sector clients are being enrolled in carve-outs, quality improvement is a high priority. The American Managed Behavioral Healthcare Organization (AMBHA) has developed its report card with input from consumer groups, such as the National Alliance for the Mentally Ill (NAMI). The Mental Health Statistics Improvement Program (MHSIP) involved consumer groups (e.g., NAMI and the National Empowerment Center) in developing a report card to evaluate mental health services. Although it is intended for all mental health services and is not specific to managed behavioral health care, the report card involved industry groups in its development. Field testing of the report card began in the summer of 1996. Employers as Purchasers As discussed in Chapter 1, employers are interested in the value of their investments in health care. They control the nature of competition among the health plans that are allowed to compete for a firm's employees and dependents. Control of competition occurs via the prequalification of plans, the initial negotiation of premiums, and the definitions of benefits and performance standards. Employees are then permitted to choose among qualified health plans. In many cases the premium subsidy is structured so that the employee must pay for pre-

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH mium costs above the cost of the lowest-priced plan. This competition for enrollees is thought to exert pressure to reduce premiums and to offer the opportunity to compete in the area of quality as well. In addition, the increased use of capitated payment methods for reimbursing health plans creates strong financial incentives for plans to reduce health care spending. Capitation refers to the practice of having fixed rates of payment for the provision of a specified group of services to a defined group of recipients. Usually, payment is made on a per-member, per-month basis. Although it is not the dominant payment method, the use of capitation to create incentives for providers and practitioners has expanded. It is estimated that in 1994 about 20 percent of the population was served by a physician who was reimbursed under a capitation arrangement (Business and Health Magazine, 1995). This passes the strong financial incentives of capitation along to individual providers of care. Report cards and public reporting of responses to patient satisfaction surveys provide opportunities for employers and employees to choose among competing health plans by comparing the relative value offered by various plans. The result of the combination of aggressive buying by employers and the use of competition has been a dramatic shift in enrollment patterns across plan types. Recent surveys by several large benefits consulting firms indicate that the portion of individuals covered by employer-sponsored insurance and enrolled in traditional indemnity plans (with or without precertification) fell from 53 percent in 1991 to 35 percent in 1994. In particular, PPOs, POS plans, and HMOs accounted for 63 percent of enrollees in employer sponsored health insurance plans in 1994 (Foster Higgins, Inc., 1994). In addition, some employers report that they have been successful in obtaining premium reductions from health plans seeking to participate in their employee health programs. The overall result has been for average employee health care costs to rise only modestly among larger employers, whereas the increases in costs for other purchasers have been larger (IOM, 1993). Financial incentives, provider selection, and utilization management techniques are used alone and in combination within most managed care plans (Freeman and Trabin, 1994; Goplerud, 1995; IOM, 1989). Financial incentives can be applied to consumers (deductibles and copayments) and providers (capitation or some other form of risk-based contracting) to discourage the use of costly services. Mandating the use of specific provider networks limits consumers' ability to choose practitioners, reduces the number of providers that can be reimbursed for care, facilitates the negotiation of contracts with favorable rates, and permits more scrutiny of the quality of care than reimbursing individual practitioners on a fee-for-service basis. Finally, utilization management applies treatment guidelines, protocols, and professional judgment through prior review (are services appropriate and necessary?) and high-cost case management (a review of high-expenditure cases to facilitate less costly care) to reduce the expense of care and enhance the consistency and quality of care (IOM, 1989).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH State Governments as Purchasers States and counties have the responsibility for managing public systems of care, and their objectives with regard to health plans and services differ somewhat from the objectives of private employers. For example, a state may place priority on offering a minimum level of access to basic medical care to achieve the lowest “on-budget” cost. The configurations and structural relationships among the Medicaid agency, state mental health and substance abuse authorities, and child welfare systems are different in each state, as are the economic and political environments, so the routes to cost-effective care differ in each state (Essock and Goldman, 1995). By August of 1996, 29 states had received federal waivers to restructure their Medicaid programs, often in response to state legislative mandates to expand coverage for poor people who would otherwise not qualify for Medicaid (GAO, 1995). Expansion of the numbers of people enrolled in the Medicaid program requires the realization of savings from care for currently covered enrollees to finance the expansion of coverage to new populations. One way to achieve the savings is through capitated health plans. As of June 1995, about 32 percent of Medicaid program beneficiaries were enrolled in capitated managed health care plans (HCFA, 1996). This segment of the Medicaid market is growing rapidly. States are active buyers of managed care services for their Medicaid enrollees and make use of competition to enter the program to obtain favorable premiums. Because Medicaid enrollees do not pay premiums, competition for enrollees is used primarily as a quality control mechanism. That is, if a plan offers insufficient quality, enrollees may choose some alternative plan that might offer more satisfactory services. CONCERNS WITH MANAGED CARE IN THE PUBLIC SECTOR The introduction of managed care into already existing public-sector service systems represents a reorganization of service delivery and creates opportunities to address many limitations of the current systems of care for individuals with mental health and substance abuse problems. Purchasers with vision can use managed care arrangements to achieve specific goals: improve access to care, enhance the quality of care, better manage the cost of care, increase the effectiveness of care, and facilitate prevention initiatives. Indeed, increased use of managed care tools can be a key strategy to facilitate improved integration of the separate and distinct public and private systems of care that are a problematic aspect of mental health and substance abuse care. However, debate on the use of managed care for behavioral health care (mental health and substance abuse treatment) can be intense because there is evidence that individuals with chronic conditions including mental illness and substance abuse may have more difficulty receiving adequate and effective services

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH when they are enrolled in managed care plans (Christianson et al., 1989; Mechanic and Aiken, 1989). One study comparing psychiatric treatment within prepaid managed care plans and fee-for-service arrangements found that half of the individuals receiving care through a managed care plan developed new functional limitations over time, whereas those receiving care through a fee-for-service plan did not (Rogers et al., 1993). Some believe that the techniques used by managed care plans can facilitate access to care and improve the quality of services because provider flexibility can be enhanced and care can be individualized; others are concerned that managed care models can inhibit access and interfere with appropriate and individualized care (e.g., Boyle and Callahan, 1995; Gold et al., 1995; Kassirer, 1995; Sabin, 1995; Schlesinger, 1995; Schlesinger and Mechanic, 1993; Surles, 1995). Moreover, the prepaid capitated financing characteristic of managed care plans is frequently distrusted because of the potential financial incentives to minimize care and maximize profits (e.g., Boyle and Callahan, 1995; Iglehart, 1996; Sharfstein and Stoline, 1992) Financial Risk Effective managed care programs manage expenditures. Purchasers can increase or decrease the amount of financial risk that a managed care organization assumes and can potentially reduce the incentives to limit access and utilization of expensive technologies, specialty services, and long-term care (Frank et al., 1995). One important component in managing costs is the analysis of the incentives and disincentives included in the contracts between the purchaser and the managed care organization and between the managed care organization and the provider. Frank and colleagues (1995) have examined public and private contracts for managed behavioral health care, and they suggest that purchasers may achieve a balance between cost control and access through the use of “soft” capitation, which shares risks between the purchaser and managed care organization, thereby reducing the potential profit and losses for the managed care organization. Soft capitation can promote reinvestment of “savings” into increased benefits or expanded eligibility by giving governments a share of the “profits. ” Public providers of community-based services who are eager to share in the potential profits related to the use of capitation have negotiated subcapitation rates. They agree to provide necessary services to a specified population for a portion of the total capitation—a subcapitation. Subcapitated providers can profit from treating patients. Each subsequent layer of subcontracting draws an administrative fee, which reduces the funds ultimately available for direct services. Inexperience with managing populations of enrollees may also lead to setting rates that are too low, thereby threatening access and quality of care.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Integrated Services Direct and insufficiently planned applications of private-sector managed care models to public-sector systems that serve men and women with serious mental illness and chronic substance abuse are unlikely to be successful. Many employer-purchased managed care plans explicitly exclude social and support services, and because they emphasize acute care, they tend to have little experience in the management of chronic and disabling conditions. Changes in service systems may also threaten the continued viability of the agencies and providers that have served the more complex and vulnerable uninsured and publicly insured consumers with distinction. At the same time, many of the tools of private-sector managed care have relevance to public-sector systems. For example, integrated management information systems, decision-making algorithms, and methods of developing and improving provider networks have great applicability to public-sector systems. The ability of public systems to implement these strategies, however, may be limited by budgetary constraints, procurement policies, personnel capacity, and other factors. Integration of service delivery across a broad range of services is a challenge to achieving effective and efficient services. Carve-in or integrated policies, most common in staff model HMOs, can increase the likelihood of coordination and communication among primary care and specialty providers. Carve-out vendors have the advantages of having better linkages with employee assistance programs, more specialized quality measurement tools, more specialized practitioners, and the ability to provide consistent benefits anywhere in the country (IOM, 1996). Integration of services requires resource management that coordinates benefits from multiple entitlements and services from diverse and multiple providers. Case management to support transitions (transition management) can help individuals moving across settings and to care outside the system. Regular screening of populations and internal referral systems among key providers are needed to support aggressive case finding and early intervention. Multidimensional assessments need to include the medical, personal care, mental health, substance abuse, and social facets of need, but comprehensive approaches are very difficult to coordinate. One way to assist in coordination is to include in contracts requirements for linkages to support wraparound services such as transportation and child care (Institute for Health Policy, 1995). BEHAVIORAL HEALTH IN THE NEW MARKETPLACE As employers and states have moved in the direction of contracting with managed care organizations to care for at-risk individuals, providers, consumers, and policymakers have become concerned about the consequences of these developments with regard to access to care and the quality of treatment for individuals suffering from mental health and substance abuse problems. Individuals

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH suffering from severe forms of mental and addictive disorders have been identified as being at risk for neglect under these new market arrangements (Boyle and Callahan, 1995). The question that stems from such concerns is, how can behavioral health care productively fit into the larger health care system? This section focuses on one dimension of making markets more accommodating to behavioral health care. That dimension involves improving the information available on the quality of health plans in providing behavioral health care services. Information on quality is one aspect of the choices available to purchasers and policymakers in the behavioral health care arena. It is, however, an important choice and arises as an issue under all types of organizational and financial arrangements, albeit in different forms. In many respects, the behavioral health care market is being transformed from transactions based on services to transactions based on people. Behavioral health care organizations are increasingly competing for the right to serve populations. In some cases, this competition comes in the forms described above, in which individuals choose from among competing health plans. In other cases, a purchaser (employers or a government) will carve out behavioral health care and will competitively select a single managed care vendor (Frank et al., 1995). Risk-sharing arrangements are increasingly common for both health plans and carve-out programs. These can involve establishing financial arrangements, utilization controls, and other mechanisms to share the financial risk of providing care among health plans or other providers, payers, and users of a health care plan. In a risk-sharing arrangement, health plans face at least some financial risk for the costs incurred on behalf of their enrollees. Initial results from the transformation of behavioral health care markets are dramatic. Managed behavioral health care has shown that in many cases it can result in significant reductions in behavioral health care spending (Mechanic et al., 1995). Treatment patterns are changing, often in directions that have long been viewed as desirable. For example, in the mental health area, adoption of a managed behavioral health care program is often accompanied by a reduced reliance on hospital-based inpatient care and a greater emphasis on community-based alternatives (Callahan et al., 1994). In the substance abuse area, managed behavioral health care plans result in dramatic reductions in the use of 28-day inpatient programs and the expanded use of residential treatment programs. Many of the criticisms of the new organizational and financial arrangements associated with managed behavioral health care stem from their efforts to respond to certain problems inherent in trying to insure health care. One of these problems involves the utilization effect of health insurance; the other is the problem of biased risk selection. The utilization effect of health insurance (sometimes called moral hazard) refers to the tendency of those who are insured to use more health services—both appropriate and inappropriate—than those people would use if they were responsible for the full cost of care. Ideally, health plans could respond with strategies

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH graft surgery is performed created a patient registry in 1987 and began a quality improvement initiative in 1990. The initiative involved three kinds of intervention: feedback of outcome data to practitioners, training in continuous quality improvement techniques, and site visits to other medical centers. Data from 1993 suggested a cumulative reduction of 74 deaths from the mortality levels expected before the quality improvement intervention —a 24 percent reduction. The five institutions made multiple changes in procedures and techniques, so there was no single cause for the decline in mortality; rather, the observed improvements were due to the net effect of their efforts to learn and improve (Berwick, 1996). Berwick (1996), in commenting on the study group's report, suggests that this type of discovery may be more valuable than randomized clinical trials for cumulative improvement and for the identification of techniques that enhance health care and reduce costs. It is also critical, he argues, that such information be reported to and published in peer-reviewed journals and not be guarded as proprietary information. The techniques and outcomes will be most useful if they are incorporated into clinical guidelines and protocols Quality Improvement in Behavioral Health Care Comparable demonstrations of the successful application of quality improvement methods to improved patient outcomes do not appear to exist for mental health and substance abuse treatment services. Both public- and private-sector treatment systems, however, have begun to adapt and apply quality improvement technologies. In Massachusetts, for example, the Quality Improvement Collaborative is a peer-reviewed total quality management initiative designed to foster the introduction and use of continuous improvement protocols within all of the substance abuse treatment programs under contract with the Massachusetts Department of Public Health's Bureau of Substance Abuse Services (Fishbein and McCarty, in press). Detoxification centers adopted and implemented a model clinical record, and methadone services standardized evaluations of their clients' progress and linked a client's progress to the phases of care; evidence of improvements in patient care, however, are not yet available. The Massachusetts Medicaid program has also applied quality improvement methods to the management of relationships with its suppliers (managed care organizations and health care providers) and reports improved responsiveness among the suppliers of health care (Friedman et al., 1995). As a result of this initiative, the managed behavioral health care organization responsible for the management of mental health and substance abuse services for the Massachusetts Medicaid program developed its own quality improvement program (Nelson et al., 1995).

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Report Cards and Performance Standards Consumer ratings of service industries have been available for many years but have only recently become available for health care. With the emergence of managed care and consideration of competing health plans, purchasers need to make decisions about what benefits they need, the amount of out-of-pocket expenses or copayments that are desired, and the choice of providers and practitioners within a plan or network. In the public sector, purchasers need to make policy decisions on behalf of publicly insured individuals in the context of the local and regional political and economic environments. A majority of the health care quality information has been geared toward employers and other purchasers, but there is a growing emphasis on providing information that will help consumers select managed care plans that provide quality and an array of services. Quality in these terms is usually measured as patient satisfaction with the services that have been received. Common dimensions include access to care, perceived quality of the contact with the provider, and outcomes of the contact, such as improvements in health status. One area of controversy has to do with the quality of the data that are used to prepare report cards. Many health plans produce their own report cards as part of a marketing strategy, and without some kind of independent verification of the data, there may be an incentive to misrepresent information. Another major concern has to do with the comparability of data from different plans, because they may have had different benefit structures, different member populations with different levels of risk, and other differences. One approach has been taken by the Pacific Business Group on Health (PBGH), a nonprofit coalition of public and private purchasers. PBGH has developed a model plan design that all members must adopt, information systems are comparable so that performance can be measured in the same ways across plans, and the data are collected and analyzed in a format that can be audited (Brown, 1996). Contracts for Purchasing Care The structure of the contract between a payer and a managed care organization and the means for monitoring and enforcing the contract are among the most important ways to influence the quality of care (Essock and Goldman, 1995). Contracts and contract language in the purchasing agreement should specify expectations about benefits and covered services, standards of care, ways of ensuring that the standards and other quality measures are met, and incentives and disincentives associated with the vendor's performance. For example, if a state agency is concerned about the possibility of a managed care organization “dumping” patients with serious mental illness into the public system, the contract could specify that the organization will have to pay a financial penalty for every day that a person covered by the contract spends in a state hospital (Essock and Goldman,

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH 1995). As a positive financial incentive, a contract might include a bonus based on the number or proportion of individuals who experience reduction in symptoms and other positive outcomes. Some large purchasers, such as the Digital Equipment Corporation and Pacific Business Group on Health, have developed their own set of standards and monitoring guidelines and requirements and include those in their contracts with managed care organizations. Some other purchasers have adopted these standards, but others may in the future require use of the standards developed by the National Committee for Quality Assurance, which are based in part on the American Managed Behavioral Healthcare Association's performance measure set, or the report card developed by the Center for Mental Health Services. These behavioral health performance measurement systems will be discussed further in Chapter 6. In an effort to control costs and improve efficiency and quality, many states are contracting with managed behavioral health companies. The development of contracts that protect and enhance care for publicly insured individuals is a new responsibility for state agencies, and technical assistance manuals for public purchasers of managed care have been developed by the Center for Substance Abuse Treatment (1994, 1995) and by the Bazelon Center for Mental Health Law (1995). ETHICAL ISSUES IN MANAGED BEHAVIORAL HEALTH CARE Quality of care necessarily raises ethical issues. Most ethical issues related to managed behavioral health care are not new or unique to managed care, either medical or behavioral health managed care. Many of these concerns also existed under fee-for-service systems, but public awareness of these concerns has been increasing as managed care has expanded. The intent of this section of the report is to review the most salient ethical concerns in relation to the quality of care. Generally, these issues revolve around confidentiality, patient autonomy, the practitioner-patient relationship, and the patient's right of appeal. Confidentiality Designating the primary care physician as the coordinator of care and requiring prior authorization for treatment and other case management activities inherent in managed care increase the necessity for sharing medical information. The primary concern about confidentiality under managed care focuses on the claim that there is a greater demand to release confidential patient information in managed care systems than under fee-for-service systems. Information is disclosed when authorization for treatment is sought and when patients are referred from one service provider or practitioner to another. These risks for breach of confidentiality are not new under the managed care system, although they are perhaps

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH more accelerated in this system because of increased efforts to centrally manage the care. Patients have increased concerns about confidentiality related to mental health or substance abuse treatment because of their fear of being stigmatized. Who is bound in the confidential relationship and thus obligated to protect the use of or prevent further disclosure of the information? The most relevant element is therefore the obligation of managed care plans to designate explicitly who can release and receive information and the limits to which it can be used. Ethicists agree that insurers, providers, and practitioners have a duty to safeguard the release of sensitive information through policy directives, information system protections, and quality assurance mechanisms (IOM, 1993). Confidentiality Regulations in Substance Abuse Treatment A unique aspect of treatment for alcoholism and drug abuse is the presence of federal regulations (42 CFR Part 2) that require that the confidentiality of information about individuals in substance abuse treatment be maintained. The regulations prohibit unauthorized disclosure of patient-specific information and limit the ways in which disclosure can occur legally. The Hughes Act (P.L. 91-616), its reauthorization (P.L. 93-282), and the Drug Abuse Prevention, Treatment, and Rehabilitation Act of 1972 (P.L. 92-255), as amended by P.L. 93-282, stipulate that treatment records are confidential and required the development of federal regulations to govern the disclosure of information from patient records (Legal Action Center, 1988, 1991; Lopez, 1994; NIDA, 1980). The regulations protect the privacy of individuals entering care and help assure men and women seeking care that their participation in treatment cannot be disclosed without their consent. The requirements are more restrictive than those related to doctor-patient or attorney-client privilege (Legal Action Center, 1991). All substance abuse treatment services that receive federal assistance, tax exemptions, or authorization to conduct business are covered by the regulations. Most treatment programs follow the guidelines developed by the Legal Action Center (1991) to facilitate the disclosure of patient information and maintain compliance with the regulations. Without special safeguards, the computerized information systems used to record diagnostic and billing information and to share clinical records within a health plan could violate the federal regulations. The confidentiality of patient records and any information about participation in treatment for alcoholism and drug abuse therefore becomes an especially complex issue within the context of managed behavioral health care.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Patient Autonomy Patient autonomy can be defined as the right of an individual to exercise free will, have choice among options, and be the decision maker in managing his or her health care. Therefore, from this perspective patient autonomy has always had certain limitations. When one seeks care from another, there is an implicit understanding that the practitioner assumes some role in managing the person's health. To the degree that an individual allows payment for his or her health care by a third party, that party becomes a stakeholder in the process and the patient's autonomy begins to be restricted. Managed care limits the choices that patients have regarding what services are available and who will provide them. This is part of the rationale under which managed care systems were created. The ethical concern is whether the restriction of choice results in limitations that affect the outcome of care. Even to the degree that managed care may mean less care, one cannot presume that this means worse or less effective care, although exposures in the media and litigated cases have occasionally provided evidence that this can occur (e.g., Goleman, 1996). Individuals have a responsibility to learn as much as they can about their health plans, including the nature of their benefits (Council on Ethical and Judicial Affairs, 1995). Respect for autonomy assumes that a patient is capable of self-determination, but the capacity of an individual patient to make sound decisions that are in his or her best interest is influenced by the nature and course of the illness, as well as by individual personality and preferences. This is true for all illnesses (Povar, 1991). Thus, the choices made by a patient may not be those recommended by the patient's clinician or family. Disregarding patient preferences by not offering options can have measurable effects on the patient 's compliance as well as the patient's outcome (Povar, 1991). This further complicates the issue of patient autonomy. However, in spite of these factors, patient autonomy and the right to make choices need to be ensured, even though reasonable limitations may exist. Practitioner-Patient Relationship The discussion of patient autonomy leads directly to the issue of the practitioner-patient relationship. In medicine, this relationship has always been considered to be based on trust (Council on Ethical and Judicial Affairs, 1995). Critics on both sides argue about the impact that managed care has on this relationship. Advocates say that a primary care physician maintains, by definition, a principal and ongoing association with the patient, serving as the coordinator of his or her medical care. Opponents of managed care believe that the structure of the system distances a patient from the physician. Large group practices, provider panels, prior authorization requirements, and arbitrary assignment

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH of a patient to a practitioner or a series of practitioners can erode the practitioner-patient relationship. There is general agreement that disrupting an established relationship is usually disadvantageous. The ethical question seems to be to what degree is this allowable without having an effect on the effectiveness of care? Do insurers and providers have an obligation to minimize the likelihood of this happening? Are such mechanisms as policy directives, service delivery structures, and quality reviews adequate safeguards and guarantees for preserving the practitioner-patient relationship? Society's expectations are the ultimate test of the fit of our measures of quality. We believe that creative dialogue about quality with consumers and persons experiencing recovery from mental illness is a professional and ethical requirement that will change and increase with society 's expectations. Sarah Stanley American Nurses Association Public Workshop, April 18, 1996, Washington, DC The role that patients play in managing their health is a theme common to the ethical concerns of confidentiality, patient autonomy, and the practitioner-patient relationship. Several factors influence what this role can or should be. These include the patient's individual personality, life situation, health history, and functional capacity and cultural background; the nature and course of the illness(es); the effectiveness of health services; and the availability of community support. The manner in which all of these dynamics converge significantly affects the effectiveness of care provided. In the course of events, the decisions made and the outcomes of these decisions can be misunderstood, or can be confusing or disturbing for patients. Patients can feel victimized by the very systems that are supposed to care for them. To empower patients, they need to receive adequate information regarding choices of treatment and to be able to provide informed consent. Social change and public policy have increased the need to involve patients in their treatment decisions. Health care providers and practitioners, ethicists would agree, have a moral duty to provide systems that empower patients, allow them to be responsible for making treatment decisions, and give them opportunities to appeal decisions made by others on their behalf.

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH Summary of Ethical Concerns Addressing the ethical issues in mental health care and addiction treatment is especially complex. This is because of the unique impact that mental illness and addiction have on the reasoning and behavior of individuals and the continuing stigma associated with mental illness and addiction. Much more than physical illness, mental illness and addiction are viewed as social as well as medical problems. The question is not whether managed care should continue in light of these ethical concerns. Rather, it is how managed care must best address and respond to these critical issues. SUMMARY This chapter has discussed some of the major trends affecting health care delivery. One major trend is the increasing numbers of individuals enrolled in managed care plans, which take a variety of forms with different delivery and financing structures. A second trend is the increasing numbers of individuals in the public sector who are being enrolled in managed care plans, including a large number of individuals with chronic and severe health problems. A third trend is the shift from exclusive concern with the cost of care to increasing interest in the quality of care, which can be described as the overall value derived from expenditures on health care on the basis of evidence of effectiveness and positive outcomes from care. John Ruskin, a nineteenth century businessman, said something I think helps us to determine where we have gotten in this field. He said: it is unwise to pay too much, but it is worse to pay too little. When you pay too much, you lose a little money. That is all. But when you pay too little, you sometimes will lose everything, because the thing you bought was incapable of doing the thing it was bought to do. William Dennis Derr Employee Assistance Professionals Association Public Workshop, April 18, 1996, Washington, DC Quality assurance in health care takes many forms, including licensure and certification of providers and practitioners, practice guidelines, report cards, performance measures, and regulatory approaches such as accreditation. Evidence of the effectiveness of different approaches is still preliminary because of the variety

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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH of quality improvement strategies and the complexity of health care. However, the committee believes that there is increasing support and consensus about the importance of quality improvement throughout the health care system. REFERENCES Akerlof G. 1970. The market for lemons: Qualitative uncertainity and the market mechanism . Quarterly Journal of Economics 84:488-500. AMBHA (American Managed Behavioral Healthcare Association). 1995. Performance Measures for Managed Behavioral Healthcare Programs. Washington, DC: The AMBHA Quality Improvement and Clinical Services Committee. AMA (American Medical Association). 1993. Directory of Practice Parameters, 1993 Edition. Chicago: American Medical Association. Bazelon Center for Mental Health Law. 1995. Managing Managed Care for Publicly Financed Mental Health Services. Washington, DC: Bazelon Center for Mental Health Law. Berwick DM. 1996. Harvesting knowledge from improvement. Journal of the American Medical Association 275:877-878. Berwick DM, Godfrey AB, Roessner J. 1991. Curing Health Care: New Strategies for Quality Improvement. San Francisco: Jossey-Bass Publishers. Birch and Davis Associates, Inc. 1984. Development of Model Professional Standards for Counselor Credentialing. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Boyle PJ, Callahan D. 1995. Managed care in mental health: The ethical issues. Health Affairs 14(3):7-22. Brown C. 1996. Purchasers' Perspectives on Quality. Presentation to the IOM Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care. Irvine, CA. May 17. Business and Health Magazine. 1993. The State of Health Care in America: 1993. Montvale, NJ: Medical Economics Publishing. Business and Health Magazine. 1995. The State of Health Care in America: 1995. Montvale, NJ: Medical Economics Publishing. Callahan JJ, Shepard DS, Beinecke RH, Larson M, Cavanaugh D. 1994. Evaluation of the Massachusetts Medicaid Mental Health/Substance Abuse Program. Submitted to the Massachusetts Division of Medical Assistance, Mental Health Substance Abuse Program. Waltham, MA: Institute for Health Policy, Brandeis University. CARF (The Rehabilitation Accreditation Commission). 1996. 1996 Standards Manual and Interpretive Guidelines for Behavioral Health. Tucson, AZ: The Rehabilitation Accreditation Commission. Christianson JB, Lurie N, Finch M, Moscovice I. 1989. Mainstreaming the mentally ill in HMOs. New Directions for Mental Health Services 43:19-28, Fall. Council on Ethical and Judicial Affairs, American Medical Association . 1995. Ethical issues in managed care. Journal of the American Medical Association 273(4):330-335. CSAT (Center for Substance Abuse Treatment). 1994. Managed Healthcare Organizational Readiness Guide and Checklist. Rockville, MD: Center for Substance Abuse Treatment. CSAT. 1995. Purchasing Managed Care Services for Alcohol and Other Drug Treatment: Essential Elements and Policy Issues. Rockvillle, MD: Center for Substance Abuse Treatment. Deming WE. 1986. Out of the Crisis. Cambridge, MA: MIT-CAES. DHHS (U.S. Department of Health and Human Services). 1993. Depression in Primary Care: Clinical Practice Guideline No. 5. Rockville, MD: Agency for Health Care Policy and Research. Digital Equipment Corporation. 1995. HMO Performance Standards. Maynard, MA: Digital Equipment Corporation.

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