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Summary INTRODUCTION With great speed and a considerable amount of controversy, managed care has proclucec3 dramatic changes in American health care. At the end of 1995, 161 million Americans more than 60 percent of the total popu- lation belonged to some form of managed health care plan (HIAA, 1996~. The movement into managed care has been especially rapid for the treatment of mental health and substance abuse (alcohol and drug) prob- lems, also known as behavioral health problems. Behavioral health prob- lems are common: every year, an estimated 52 million Americans have some kind of mental health or substance abuse problem (see Table ~ ). At the end of 1995, the behavioral health benefits of nearly 142 million people were managed, with 124 million in specialty managed behavioral health care programs and 16.9 million in a health maintenance organiza- tion (HMO) (Open Mincis, 1996~. HMOs, preferred provider organizations (PPOs), point-of-service plans, and other forms of managed care networks, such as managed behav- ioral health care organizations, differ in their organizational structures, types of practitioners and services, access strategies, payment for practi- tioners, and other features. Their goals, however, are similar: to control costs through improved efficiency and coorclination, to reduce unneces- sary or inappropriate utilization, to increase access to preventive care, and 1

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2 MANAGING MANAGED CARE TABLE 1 Estimated Annual Prevalence of Behavioral Health Problems in the United States (Ages 15-54) Behavioral Health Problems Prevalence No. of People (percent) (millions) All behavioral health problems (i.e., mental disorders, alcoholism, and drug addiction) Any mental disorder Any substance abuse or dependence (i.e., alcohol and illicit drugs) Both mental disorder and substance abuse or dependence 29.5 22.9 .3 4.7 52 40 20 8 NOTE Prevalence data have been collected from the National Comorbidity Survey (NCS), a congressionally mandated survey designed to study the comorbidity of substance use disorders and nonsubstance use-related psychiatric disorders in the United States. The survey was administered by the staff of the Survey Research Center at the University of Michigan between 1990 and 1992. NCS surveyed 8,098 noninstitutionalized participants with a structured psychiatric interview con- ducted by lay interviewers using a revised version of the Composite International Diagnostic Inter- view (CIDI). CIDI is a structured diagnostic interview based on the National Institute of Mental Health's (NIMH's) Diagnostic Interview Schedule, which can be used by trained interviewers who are not clinicians (Kessler et al., 1994). SOURCE Kessler et al. ( 1994) and SAMHSA ( 1995 ). to maintain or improve the quality of care (IOM, 1996a; Miller and Luft, 1 994). Both private-sector employers and public-sector agencies (Meclicaicl anc3 state mental health anc3 substance abuse authorities) have turned to managed behavioral health care companies to control costs anc3 improve quality anc3 access for mental health anc3 substance abuse care. Traclition- ally, insurance benefits for mental health anc3 substance abuse care have been more limited compared with benefits for physical health, anc3 for mental health anc3 substance abuse care there also have been few alterna- tives to hospitalization. In the late 1980s, the majority (70 percent) of funds for mental health care spent by Meclicaic3 anc3 private insurance went for inpatient care, leacling many researchers, clinicians, anc3 advocates to question the imbalance anc3 to search for policy changes. Only the introduction of managed care arrangements has led to a sig- nificant shift away from costly and often unnecessary inpatient stays to a more appropriate range of outpatient anc3 community-basec3 care. In sum, behavioral health care offers purchasers the potential to spread existing resources farther by paying for less intensive (anc3 less expensive) treat

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SUMMARY 3 ment strategies that can help patients return to a reasonable level of func' tioning, such as being able to return to work or school (England anc3 Vaccaro, 1991 ). The controversies in managed care are less about the goal of cost re' Suctions anc3 are more about the ways in which cost reductions are achieved. Methods of cost control include authorizing only certain practi' tioners who are uncler contract to provide services to an enrolled popular tion, reviewing treatment decisions, closely monitoring high~cost cases, reducing the number of clays for inpatient hospital stays, anc3 increasing the use of less expensive alternatives to hospitalization (Iglehart, 1996; Shore and Beigel, 1996~. In the committee's view, managed care strategies are not inherently harmful anc3 can be appropriate anc3 helpful, as in the shift from inpatient to outpatient care, the aciclitional supervision for complex cases, anc3 ap' plications of stanciarcis based on best practices. However, certain activities of companies that provide behavioral health care, such as limiting or clef eying services that may be needed or appropriate, adding barriers to access to care such as increased copayments for outpatient visits, anc3 addling gatekeepers who change the practitioner~patient relationship, can have an adverse impact on patient outcomes (Mechanic et al., 19951. All of our purchasers, including government and private purchasers, are looking at setting up outcomes and performance measures. Everybody has their own idea about what's a good outcome. Unless there can be some sort of consensus about what that means, ~ think increasingly we're going to see plans that are going to be ineffective at measuring outcomes. Michae/ Jeffrey Wi//iam R. Mercer, /nc. Public Workshop, May 77, 7996, /n/ine, CA The overall impact of managed care on the quality of health care is difficult to determine. For example, managed care has many structures, anc3 comparisons across organizational forms (e.g., HMOs versus PPOs) are difficult. In abolition, the quality of health care is difficult to measure

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4 MANAGING MANAGED CARE anc3 define because of the complexity of health care anc3 because of the variety of opinions about quality. The Institute of Medicine (IOM) has ciefinec3 quality of care as "the degree to which health services for incli- vicluals anc3 populations increase the likelihood of ciesirec3 health outcomes anc3 are consistent with current professional knowledge" (IOM, 199Oa, p. 21~. Each component of this definition has variations health services (e.g., primary care anc3 specialty drug abuse, alcoholism, anc3 mental health treatment in different practice settings, including hospital- based anc3 office-basec3 practices anc3 hearth centers), inclivicluals (e.g., differences among children, adolescents, adults, anc3 seniors, as well as gender cliffer- ences), populations (e.g., cultural differences anc3 differences between ru- ral anc3 urban populations), anc3 outcomes (e.g., cure, relapse prevention, anc3 return to functioning). The combinations are virtually unlimited. The challenge of accountability studies is how we build report cards that report consistent, credible, and verifiable data back to the patients and the people who are trying to pick which HMO or PRO they're going to join. Ran c/a// Mac/ry Utilization Review Accrec/itation Commission Public Workshop, May 17, 1996, Irvine, CA Public interest in quality of care is keen, anc3 purchasers are interested in information that can help them make decisions on the value anc3 effec- tiveness of different managed care options. Several approaches have cle- velopec3 to assess the quality of care: accreditation, licensing anc3 certifica- tion, creclentialing and privileging, practice guiclelines, performance measures, report carcis, anc3 other means (see Figure ~ ). Many of these ap- proaches are unfamiliar to most consumers, but HMO ratings, aciaptec3 from product anc3 service rating systems such as those cievelopec3 by Con' sumer Reports, reach a wide audience through national magazines such as Time, U.S. News arid World Report, anc3 Neqvsqueek anc3 in national news- papers including The Wall Street fourrral, The New York Times, anc3 USA Today. When new measures of health care quality such as report carcis are aclclecl to the traditional approaches, primarily accreditation and licensure

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SUMMARY EXTERNAL: ACCOUNTABILITY Accreditation Licensure Specialty Certification Peer Review Audits Utilization Management Utilization Review Media Reports s INTERNAL: IMPROVEMENT Clinical Protocols Clinical Outcomes Data Clinical Supervision Provider and Clinician Profiling Performance Measures Consumer Satisfaction Appeals and Grievance Procedures Promptness of Paying Claims BOTH Managed Care Contract Language Standards 1 1 1 Guidelines 1 Performance Measures 1 | Indicators l 1 ~1 Report Cards FIGURE 1 Framework for quality assessment. The figure displays a wide array of activ- ities that can have an impact on the quality of care. Impact may vary depending on the level of responsibility for quality of care within an organization, the regulatory mecha- nisms that apply, the nature and extent of the relevant outcomes research base, and other factors.

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6 MANAGING MANAGED CARE of practitioners and facilities, quality assessment becomes a complex patch- work of mechanisms. Federal, state, anc3 local governments, accreditation organizations, managed care organizations, purchaser coalitions, consumer groups, professional organizations, anc3 the media are actively involved in providing information on the quality of health care. Some of these efforts are collaborative, but some are competitive. Overall, the picture is incom- plete, inconsistent, anc3 inadequate for making truly informed decisions about the quality of health care services. To those who are responsible for purchasing care, the absence of consensus on quality measurement makes it very difficult to make decisions. When you think about it, every organization be it a managed care organization, an insurer, a hospital, an integrated delivery system, whatever has huge financial systems that literally aggregate and track hundreds if not thousands of financial transactions. On the quality side, we pull ~ O charts and do a review. John Bartlett American Managec/ Behaviora/ Hea/thcare Association Public Workshop, April is, 1996, Washington, DC DESCRIPTION OF THE STUDY In the spring of 1995, the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse anc3 Mental Health Services Ac3- ministration (SAMHSA) in the U.S. Department of Health anc3 Human Services (DHHS), asked the IOM to convene an expert committee that would consider issues related to quality assurance anc3 accreditation in managed behavioral health care. As part of SAMHSA's Managecl Care Initiative, CSAT was the lead agency in the effort, with aciclitional sup- port from SAMHSA's Center for Mental Health Services (CMHS) and Center for Substance Abuse Prevention (CSAP). A ~ 7-member committee was chosen to carry out this effort. The mem- bers had expertise with national accreditation processes anc3 procedures, publicly anc3 privately financed managed care organizations, employee as

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SUMMARY 7 sistance programs, corporate and public purchasing of mental health and substance abuse services, public and private medical administration, and health services research. The committee also included individuals who had experience as direct consumers of behavioral health care or as family members of consumers. The charge to the committee was to develop a framework to guide the development, use, and evaluation of performance indicators, accredita' tion standards, and quality improvement mechanisms. The framework could then be used to assist consumers and other purchasers of publicly and privately financed care with the purchase of the most effective man' aged behavioral health care at the lowest appropriate price. The committee identified a variety of stakeholders as the audience for the report. These included accreditation organizations, managed care com' panics, federal and state governments, community~based treatment orga' nizations, health services researchers, practitioners, consumers, and other interested parties. In carrying out this task, the committee operated on a clear premise: the ultimate goal of the work was to improve the quality of care for people with behavioral health problems. The committee met five times between February and July 1996. To gather information to assist in its deliberations, the committee convened two public workshops. The first workshop was held in Washington, DC, in April 1996, and included 25 speakers representing national accredita' tion organizations, the behavioral health industry, professional associa' tions, and consumer and advocacy groups. The second workshop was held in Irvine, California, in May 1996, and included nine speakers represent' ing accreditation organizations, a benefits consulting firm, a purchasing cooperative, and the behavioral health care industry. An additional seven speakers were invited to the committee's fourth meeting in June 1996 to discuss consumer issues specific to children, older adults, and seriously mentally ill individuals; quality improvement activities in the military health care system; and culturally appropriate care for Native Americans, Asian Americans, and Hispanic Americans. In addition to these workshops and presentations, liaison panels were formed with more than 150 representatives of national accreditation groups, national professional associations, consumer and advocacy groups, managed care industry groups, and federal and state agencies. Members of the liaison panels were invited to attend the public workshops and re' ceived information regarding the study at various stages (e.g., meeting dates and workshop agendas). More than 40 members of the liaison panels also provided written statements for the committee's consideration.

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8 MANAGING MANAGED CARE The committee reviewed the available medical, psychosocial, anc3 health services research on the outcomes anc3 effectiveness of treatment in managed care. The committee also sought other empirical findings to in- form its deliberations, including current activities anc3 surveys in the man- agec3 behavioral health care industry, including those performed by the American Managed Behavioral Healthcare Association (AMBHA) anc3 the Institute for Behavioral Healthcare, as well as documents anc3 reports from federal agencies such as the CSAT anc3 CMHS, the National Insti- tute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse anc3 Alcoholism (NIAAA), anc3 the Health Care Financing Administration (HCFA). The committee also reviewed descriptions of five accreditation orga- nizations: the Rehabilitation Accreditation Commission (formerly the Commission on Accreditation of Rehabilitation Facilities) (CARF), the Council on Accreditation of Services for Families anc3 Children (COA), the Joint Commission on Accreditation of Healthcare Organizations (ICAHO), the National Committee for Quality Assurance (NCQA), anc3 the Utilization Review Accreditation Commission (URAC). In abolition, the committee reviewed the following previous reports by the IOM: Con- trollir~gCosts arid Char~gir~gPatier~t Care? The Role of Utitizatiorr Marragemer~t ~1989), Medicare: A Strategy for Quality Assurance ~199Oa), Ctirlical Prac- tice Guidelirres: Directions for a New Program (199Ob), Broaderrir~g the Base of Treatment for Alcohol Problems ~ ~ 990c), Treating Drug Problems ~ ~ 9903), Employmer~t arid Health Benefits ( 1993 ), Primary Care: America's Health ire a New Era (1996a), anc3 Pathways of Addictiorr: Opportunities ire Drug Abuse Research ~ 1996b). However, the committee also recognized that many of the stucly's most important questions could not be answered solely by searching the avail- able clinical anc3 policy research anc3 health care industry literature. To provide a context for this report, the committee clevelopec3 a set of prin- ciples that is based on empirical evidence, but that also relies on a consic3- eration of issues that may not have been examined empirically. These prin- ciples are reflections of a current uncierstancling of strategies for improving the quality of care anc3 also reflect ethical concerns that have emerged through the incliviclual committee members' professional anc3 personal ex- periences in the delivery anc3 study of health care.

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SUMMARY STATEMENT OF PRINCIPLES 9 i. Helping to improve the quality of life for inclivicluals, families, anc3 those responsible for the legal anc3 financial circumstances of those inclivicluals anc3 families should be the heart of all efforts to improve the quality of behavioral health care. 2. Because treatment is effective for mental health anc3 substance abuse problems, it is an essential part of health care anc3 should be access sible to all. Behavioral conditions should be viewed as clinical conditions, both in the provision of (anc3 access to) preventive interventions anc3 treat' ment anc3 in the requirements for quality anc3 patient satisfaction. 3. Activities to improve the quality of health care should be based on evidence of effectiveness whenever possible. Every group among the stakeholclers consumers, practitioners, purchasers, managed care com' panics, accreditation organizations, anc3 other groups must share respon' sibility for the quality of treatment. Commitment to improving quality should be inherent in any agreement to provide or receive care. 4. The expense of successful anc3 appropriate treatment for mental health anc3 substance abuse problems can be a barrier anc3 a burden, put' tiny inclivicluals anc3 families at substantial financial risk. However, un' treated behavioral health problems are also costly to inclivicluals, families, businesses, anc3 the rest of society. Thus, providing insurance coverage against the financial risks of behavioral health problems anc3 guaranteeing access to treatment can be justified on grounds of fairness as well as effi' ctency. 5. Managed care technologies offer an opportunity to increase ac' cess to preventive interventions ancl to control costs without imposing special limits ancl excessive cost~sharing. However, managed care can also bring risks of unclertreatment ancl concerns about quality. 6. Vulnerable anc3 clisablec3 populations are potentially most at risk from the failures in the managed behavioral health care market. Particular l ~ attention should be paid to the impact of managed care on such popula' Lions, which include chilclren, seniors, people from diverse cultural back- grouncis, people who live in rural anc3 other medically uncierservec3 areas, people who live in poverty, people who have developmental ancl other disabilities, people with co~occurring clisorclers (e.g., depression anc3 alco' holism), ancl people who have the most severe forms of mental illness ancl aclcliction. 7 Quality improvement ancl accreditation are two important tools

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10 MANAGING MANAGED CARE that can be used to protect anc3 improve the quality of care. In general, quality mechanisms should be used to improve performance anc3 reward best practices. 8. This committee adopts the definition of quality of care bevels open by another TOM committee: "the degree to which health services for inclivicluals anc3 populations increase the likelihood of clesirec3 health out' comes anc3 are consistent with current professional knowledge" (IOM, 199Oa, p. 211. 9. Quality of care includes several components. These include (~) a real opportunity for the person being treated to have a reasonable range of practitioners anc3 treatment options from which to choose, anc3 to pro' vine informed consent (by the person being treated or by a clesignatec3 representative, the approval of, anc3 agreement with, the decision or ac' Lions taken by the providers; (2) the protection of confidentiality anc3 privacy rights, balanced with the need to share clinical information to improve the coordination of care; (3) a ciemonstratec3 respect for the cul' rural context of the incliviclual anc3 community being served; anc3 (4) an emphasis on functional assessments, such as a return to work or school, as measures of success. 10. Behavioral health problems require an array of preventive anc3 treatment services that are coorclinatec3 into a continuum of care that in' tegrates worksites and schools with all parts of the medical treatment sys' rem, as well as with community~basec3 services. Accreditation and Quality Assurance Many methods are being used to protect consumers anc3 improve the quality of care in this environment of rapid change. The charge anc3 focus of this committee was on managed care, particularly with two prominent strategies: accreditation of managed care entities anc3 the use of perfor' mance indicators. However, the committee recognized that other issues, such as licensure of practitioners anc3 state inspection anc3 certification of provider agencies, play critical roles in consumer protection. Thus, the committee also consicierec3 complementary strategies that can aid in con' sumer protection anc3 quality improvement, such as consumer choice of health plans anc3 better integration of outcomes research anc3 clinical prac' trace.

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SUMMARY 11 Will accreditation markedly change the quality of patient care? It may make the system better. It may make the system appear more efficient. But the principal question is, what happens to the patient? Mark Parrino American Methac/one Treatment Association Public Workshop, April is, 7996, Washington, DC This approach was required, in the committee's view, given the inter- relatec3, significant, anc3 complex changes that are uncier way anc3 the vul- nerability of inclivicluals who suffer from serious mental illness anc3 aciclic- tions to alcohol anc3 other drugs. There is increasing evidence that treatment for mental illness, substance abuse, anc3 other behavioral health problems is effective anc3 that its effectiveness is generally comparable to that of treatment in other parts of medicine. In the committee's view, therefore, robust steps are essential to address consumer protection and quality improvements, particularly through improved accreditation and performance measurement systems. Although many of the committee's concerns about quality are unique to behavioral health care, any study of accreditation anc3 other quality assurance strategies also has relevance to the general health care system. The processes of accreditation anc3 quality assurance are fundamentally the same in the primary care and specialty sectors, and the role of primary care practitioners contributes to the evaluation anc3 delivery of behavioral health care. Furthermore, all sectors of the health care delivery system are responding to the same clemancis from policy makers anc3 the public for accountability anc3 cost-effectiveness. Framework for the Study and the Report To provide a framework for the study, the committee aciaptec3 the work of Aveclis Donabeclian, a distinguished public health economist and mem- ber of the TOM who has written several books anc3 articles on the assess- ment anc3 monitoring of quality. Donabeclian has ciescribec3 three interre- latec3 ways to uncierstanc3 anc3 measure quality: structure, process, anc3 outcomes. Measures of structure include the types of services available, qualifications of practitioners, staffing patterns, adherence to building and

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SUMMARY Provider Inclusion 43 2.6 Because managed care methods are increasingly applied to pub- lic systems, accreditation bodies anc3 managed care plans should evaluate the inclusion of a variety of types of practitioners, including substance abuse counselors anc3 mental health workers, in provider panels; collect information on practitioner effectiveness; anc3 remove any practitioners from networks only for performance reasons (e.g., poor outcomes and poor consumer satisfaction). 2.6.1 The Substance Abuse anc3 Mental Health Services Ac3- ministration (SAMHSA), Agency for Health Care Policy anc3 Research (AHCPR), Health Resources anc3 Services Administration (HRSA), anc3 National Institutes of Health (NIH) (National Institute on Alcohol Abuse anc3 Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], anc3 National Institute of Mental Health [NIMH]) should cosponsor re- search to evaluate the components of treatment that are most effective in providing behavioral health care, including strategies used by psychiatrists, psychologists, social workers, counselors, anc3 primary care practitioners. 2.6.2 The Substance Abuse anc3 Mental Health Services Ac3- ministration (SAMHSA), Agency for Health Care Policy anc3 Research (AHCPR), Health Resources anc3 Services Administration (HRSA), anc3 National Institutes of Health (NIH) (National Institute on Alcohol Abuse anc3 Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], anc3 National Institute of Mental Health [NIMH]) should cosponsor re- search 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 . Inclivicluals who have been treated for severe mental health prob- lems are most often referred to as "consumers," both by the inclivicluals themselves and by the organizations that represent them. Consumers and families strongly desire to participate fully in cle- cision-making in treatment, setting behavioral health care stanciarcis, anc3 developing performance measures.

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44 MANAGING MANAGED CARE Public behavioral health service systems make use of self-help groups, consumer-operatec3 services, anc3 experientially trained counselors (e.g., mental health workers anc3 substance abuse counselors) as service providers. These practices are both valuable anc3 highly valued in these systems because they help to support consumers ancl, for example, to assist with medication compliance. Quality measures are being clevelopec3 by organizations with vari- ous degrees of involvement by consumers anc3 consumer groups. Among consumers, the report card cievelopec3 by the Center for Mental Health Services (CMHS) is viewed as having the most consumer involvement. Recommendations 3.! Health care purchasers must be responsive to consumers anc3 families anc3 should develop means of ensuring their meaningful participa- tion in treatment decisions, measurement of satisfaction, anc3 measure- ment 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 mea- sures should include all stakeholciers, including consumers, families, prac- titioners, anc3 researchers. 4. CULTURAL COMPETENCE Findings . appropriate care. Racial anc3 ethnic minorities frequently lack access to culturally In the effort to create smaller anc3 more efficient provider net- works, there is a risk of eliminating providers and groups who have special expertise with different cultures anc3 different healing practices (e.g., Afrocentric counseling anc3 Spanish-speaking services, sweat lodges for Native Americans, anc3 American Sign Language services for inclivicluals who are deaf). Often, the reason given for exclusion of cultural practices is that accepted evidence of effectiveness floes not exist. The committee observes, however, that controlled trials or other outcomes assessments have not been clone for many, if not most, medical treatments.

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SUMMARY Recommendations 45 4.! Health plans anc3 programs should be responsive to community demographics anc3 to the cultural needs of the populations that they serve. 4.2 Practitioners of alternative anc3 innovative treatments without an accepted research base should not arbitrarily be excluclec3 from health plans. If these treatments are used, their effectiveness should be stucliec3 so that stanciarcis of quality improvement can be cievelopec3. 4.3 Health plans should have an explicit mechanism for evaluating new anc3 innovative techniques anc3 types of practitioners. 5. SPECIAL POPULATIONS Findings People with disabilities, such as inclivicluals 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. Inclivicluals who have child care responsibilities, most of whom are women, often have barriers to participating in treatment. Inclivicluals who have co~occurring substance abuse anc3 mental health problems need coorclinatec3 care to maintain their recovery. Recommendations 5.! Research is needled to identify incentives for plans to serve vul' nerable populations. The Substance Abuse anc3 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 evalu' ate the needs of those groups through reviews of research literature, con' sumer surveys, anc3 other appropriate mechanisms. 5.3 All plans should meet the same core stanciarcis. Supplemental stanciarcis can be cievelopec3 for special populations, whether they are in standalone programs or in mainstream plans, for example, for a child of an employed person with family coverage.

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46 6. RESEARCH Findings MANAGING MANAGED CARE Health services research stimulates collaboration among provic3' ers, researchers, anc3 managed care organizations anc3 can facilitate the cle' velopment of valid anc3 useful measures of treatment processes anc3 out' comes through such collaborations. Research anc3 practice interact too infrequently, anc3 few incen' fives exist for collaboration among researchers, practitioners, anc3 policymakers. Outcomes research is often unresponsive to emerging problems in clinical practice anc3 also rarely provides direction for accreditation anc3 quality improvement efforts. The federal government plays a key role in the support of health services research anc3 thus in the development of the necessary knowledge base for improving the quality of behavioral health care. Recommendations 6. ~ The committee recommencis continued development of collabo' rative health services research in substance abuse anc3 mental health, anc3 encourages the Agency for Health Care Policy anc3 Research (AHCPR), Centers for Disease Control anc3 Prevention (CDC), Health Resources anc3 Services Administration (HRSA), National Institutes of Health (NIH) (National Institute on Alcohol Abuse anc3 Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], anc3 the National Institute of Mental Health ENIMH]), anc3 Substance Abuse anc3 Mental Health Ser' vices Administration (SAMHSA) to maintain, to evaluate, anc3, where necessary, to expand programs anc3 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 practi' tioner types anc3 for consumers with different needs. 6.3 Researchers should become more involved in studies carried out in managed care organizations and community~basecl settings and in other clinical outcomes research used to develop stanciarcis anc3 performance measures.

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SUMMARY 7. WORKPLACE Findings environments. 47 Society anc3 incliviclual workers need safe anc3 supportive work The federal government has responclec3 through the passage of legislation (e.g., the Family anc3 Medical Leave Act anc3 the Americans with Disabilities Act) anc3 regulations concerning safety anc3 other stan- clarcls. The workplace environment provides an excellent arena in which to aciciress behavioral health problems. Recommendations 7.! Employers should investigate the benefits of wellness activities, employee assistance programs, anc3 health risk reduction initiatives that enhance prevention, early intervention, access, anc3 treatment adherence for health anc3 behavioral health problems. 7.2 The Substance Abuse anc3 Mental Health Services Aciministra- tion (SAMHSA) should identify models of successful behavioral health programs in the workplace anc3 increase public awareness of these models. 8. WRAPAROUND SERVICES Findings For long-term recovery to be sustained, the social aspects of con- sumers' lives must be aciciressec3 as part of the behavioral health care pro- viciec3. Medical anc3 managed care models often c30 not take these reha- bilitative and support services into account. In the substance abuse fielcl, these are known as wraparound services anc3 in the mental health field they are also known as enabling services. Some symptoms of mental illness anc3 substance abuse such as severe anxiety anc3 depression, active psychosis, anc3 substance abuse with- cirawal interfere with social judgment anc3 functioning.

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48 Recommendations MANAGING MANAGED CARE 8.1 Further research is neeciec3 to prioritize the essential components of a treatment regimen that can aciciress adequately the complex behav- ioral aspects of recovery from alcoholism anc3 other drug afflictions. 8.2 To maximize full functioning for inclivicluals with severe anc3 per- sistent mental illness, anc3 to optimize conditions supporting recovery for inclivicluals with chronic substance abuse problems, wraparound services such as social welfare, housing, vocational, anc3 rehabilitative services should be available anc3 should be coorclinatec3. 8.3 For children anc3 adolescents with severe emotional disturbances, educational anc3 home environment-family support services should be co- orclinatec3 anc3 integrated with mental health care. 8.4 Accreditation systems must aciciress the social anc3 rehabilitative aspects as well as the medical aspects of comprehensive treatment for ac3- cliction anc3 severe anc3 persistent mental illness. 9. CHILDREN AND ADOLESCENTS Findings Services for children anc3 adolescents are fragmented across many different agencies, such as mental health, child abuse anc3 neglect, anc3 , Juven1 .e Justice. Many treatment models focus on a high-risk child or adolescent anc3 c30 not involve the family or other caretakers. Developmentally appropriate, comprehensive models for inter- vention anc3 treatment for adolescents are not well-ciefinec3 or applied in the current public anc3 private systems. The needs of many high-risk youth are unmet because traditional systems c30 not focus on this population. Prevention and treatment programs for mental health and sub- stance abuse problems are not adequately linked. Recommendations 9.! The Substance Abuse anc3 Mental Health Services Aciministra- tion (SAMHSA), National Institutes of Health (NTH) (National Insti- tute on Alcoholism anc3 Alcohol Abuse ENIAAA], National Institute on Drug Abuse ENIDA], and National Institute of Mental Health ENIMH]),

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SUMMARY 49 anc3 the Health Research anc3 Services Administration (HRSA) should identify exemplary models of coorclinatec3 systems of care for children anc3 adolescents. 9.2 The Substance Abuse anc3 Mental Health Services Aciministra- tion (SAMHSA), National Institutes of Health (NIH) (National Insti- tute on Alcoholism anc3 Alcohol Abuse ENIAAA], National Institute on Drug Abuse ENIDA], anc3 National Institute of Mental Health ENIMH]), anc3 the Health Research anc3 Services Administration (HRSA) should identify exemplary models of linking behavioral health treatment anc3 pre- vention programs for children anc3 adolescents to aciciress suicide, substance abuse, and other areas. 9.3 The Substance Abuse anc3 Mental Health Services Aciministra- tion (SAMHSA), National Institutes of Health (NTH) (National Insti- tute on Alcoholism anc3 Alcohol Abuse ENIAAA], National Institute on Drug Abuse ENIDA], and National Institute of Mental Health ENIMH]), and the Health Research and Services Aclministration (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 anc3 private systems must make efforts to develop ser- vice capabilities to meet the needs of adolescents who are abusing alcohol or drugs anc3 adolescents who have mental health problems. 10. CLINICAL PRACTICE GUIDELINES i, Findings Practice guidelines are clevelopec3 by professional organizations, managed care organizations, anc3 other groups. The development of guicie- lines is not always systematic, anc3 guidelines are not always linked to em- pirical findings. Little or no information is available on successful strategies for mplementing guidelines. Accreclitation tends to measure whether plans or managed care organizations have guidelines in place anc3 floes not aciciress the quality of the guidelines used by plans or organizations, or the extent to which care is actually monitored anc3 changed according to those guidelines.

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so Recommendations MANAGING MANAGED CARE 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 guide- lines 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 develop- ment 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. care . Few guidelines exist for behavioral health treatment in primary 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 ex- panded 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 pro- fessionals" ~ IOM, 1 996a, p. 13 7 ). 11.2 This committee recommends that the above recommendation include alcohol and other drug abuse problems as a defined area of exper- tise.

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SUMMARY 12. ETHICAL CONCERNS Findings . 51 The field of health care ethics embodies ethical principles that address risks in the areas of autonomy, access, informed consent, practitio- ner-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, al- though the incentives, risks, and oversight strategies differ in the two set- tings. 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: . cures. . cedures. . a clear description of a plan, its benefits, and grievance proce accessible and responsive grievance, complaint, and appeals pro effective strategies to maintain confidentiality while meeting the needs of practitioners to coordinate care, . i, n the network, resolution, . culturally appropriate and gender-specific service practitioners consumer surveys and measures of consumer satisfaction, consumer representation on policy development and grievance continuous improvement protocols to promote better outcomes, and no contractual or other limitations for physicians and other prac- titioners concerning the discussion of clinically appropriate treatment op- tions with patients and families. 12.2 A careful review of ethical issues in various settings, for example,

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52 MANAGING MANAGED CARE managed care organizations, networks, anc3 fee~for~service settings, is neeciec3. The Substance Abuse anc3 Mental Health Services Aciministra' tion (SAMHSA), Health Care Financing Agency (HCFA), and Agency for Health Care Policy anc3 Research (AHCPR) shouic3 develop a plan to examine ethical issues. CONCLUDING OBSERVATIONS In developing these recommendations, the committee was mincifu! of the rapid rate of change in the health care system anc3 the need to antic)' pate new directions anc3 trencis. This report is therefore intenciec3 to pro' vine a general, overarching framework that shows how all of the varied current anc3 fixture quality improvement activities can relate, anc3 that also may support creative anc3 collaborative initiatives to improve the quality of care. The committee's intention is that each recommendation might be implemented in a variety of ways, clepencling on the concerns anc3 capacity of the state or local agencies, managed care organizations, community' based treatment groups, consumer groups, professional associations, or other groups that are considering these issues. The committee agreed that all of the stakehoIclers consumers, prac' titioners, public anc3 private purchasers, managed care companies, accredit ration organizations, and other citizens and groups with a stake in the qual' ity of care can anc3 shouic3 work together to reach a coorclinatec3, collaborative, anc3 consensus~basec3 approach to quality measurement anc3 treatment. Efforts to achieve consensus, both on definitions anc3 measures of quality, are a good investment in the effort to provide the highest- quality care at the lowest appropriate price. REFERENCES EAPA (Employee Assistance Protessionals Association, Inc.). 1995. Glossary of Employee Assis- tance Terminology. Arlington, VA: Employee Assistance Professionals Association, Inc. EBRI (Employee Benefit Research Institute). 1996. EBRI Issue Brief. February. England MJ, Vaccaro VA. 1991. New systems to manage mental health care. Health Affairs 10(4): 129-137. GHAA (Group Health Association of America). 1996. 1995 National Directory of HMOs. Washing- ton, DC: Group Health Association of America. HIAA (Health Insurance Association of America). 1996. Sourcebook of Health Insurance Data, 1995. Washington, DC: Health Insurance Association of America. Iglehart JK. 1996. Health policy report: Managed care and mental health. The New England Journal of Medicine 334(2):131-135. IOM (Institute of Medicine). 1989. Controlling Costs and Changing Patient Care? The Role of Utilization Management. Washington, DC: National Academy Press.

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SUMMARY 53 IOM. 1990a. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press. IOM. 1990b. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: Na- tional Academy Press. IOM. 1990c. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press. IOM. 1990d. Treating Drug Problems. Vol. 1. Washington, DC: National Academy Press. IOM. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: National Academy Press. IOM. 1996a. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press. IOM. 1996b. Pathways of Addiction: Opportunities in Drug Abuse Research. Washington, DC: National Academy Press. JCAHO (Joint Commission on Accreditation of Healthcare Organizations). 1996. Comprehensive Accreditation Manualfor Health Care Networks. Chicago, IL: Joint Commission on Accredita- tion of Healthcare Organizations. Kessler RC, McGonagle KA, Zhao S. Nelson CB, Hughes M, et al. 1994. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psy- chiatry 51:8-19. Mechanic D, Schlesinger M, McAlpine DD. 1995. Management of mental health and substance abuse services: State of the art and early results. The Milbank Quarterly 73(1):19-55. Miller RH, Luft HS. 1994. Managed care plan performance since 1980: A literature analysis. Journal of the American Medical Association 271(19):1512-1519. NCQA (National Committee for Quality Assurance). 1995. Standards for Accreditation, 1995 Edi- tion. Washington, DC: National Committee for Quality Assurance. Open Minds. 1996. Managed Behavioral Health Market Share in the United States, 1996-1997. Gettysburg, PA: Open Minds. SAIC (Science Applications International Corporation). 1995. A Comparison of JCAHO and NCQA Quality Oversight Programs. National Quality Monitoring Project, Task lb, Submitted to the Office of the Assistant Secretary of Defense, Health Affairs. Beaverton, OR: Science Applica- tions International Corporation. SAMHSA (Substance Abuse and Mental Health Services Administration). 1995. Substance Abuse and Mental Health Statistics Sourcebook. Publication No. (SMA) 95-3064. Washington, DC: U.S. Government Printing Office. Shore ME, Beigel A. 1996. The challenges posed by managed behavioral health care. The New England Journal of Medicine 339(2): 116-118. Slaven T. 1996. Personal communication to the Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care. Rehabilitation Accreditation Commission. May. Stair T. 1996. Personal communication to the Institute of Medicine. Open Minds. October. United HealthCare Corporation. 1994. The Managed Care Resource: The Language of Managed Health Care and Organized Health Care Systems. Minnetonka, MN: United HealthCare Cor- poration.