NATIONAL ACADEMY PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
Support for this project was provided by the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for the project.
Library of Congress Cataloging-in-Publication Data
Managing managed care : quality improvements in behavioral health / Margaret Edmunds . . . [et al.], editors ; Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care, Division of Neuroscience and Behavioral Health [and] Division of Health Care Services, Institute of Medicine.
1. Managed mental health care—United States—Quality control. 2. Managed mental health care—Accreditation—United States. I. Edmunds, Margaret. II. Institute of Medicine (U.S.). Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care.
[DNLM: 1. Mental Health Services—organization & administration—United States. 2. Managed Care Programs—organization & administration—United States. 3. Quality Assurance, Health Care—standards—United States. WM 30 M2666 1997]
for Library of Congress
Copyright 1997 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.
COMMITTEE ON QUALITY ASSURANCE AND ACCREDITATION GUIDELINES FOR MANAGED BEHAVIORAL HEALTH CARE
JEROME H. GROSSMAN * (Chair), Chairman and Chief Executive Officer,
Health Quality LLC, Boston, MA, and Scholar-in-Residence, Institute of Medicine, National Academy of Sciences, Washington, DC
ROBERT BOORSTIN, Mental Health Advocate,
JOHN J. BURKE, Executive Vice President,
Value Behavioral Health EAP Services, Falls Church, VA
M. AUDREY BURNAM, Senior Behavioral Scientist, Co-Director,
Drug Policy Research Center, RAND, Santa Monica, CA
BARBARA CIMAGLIO, Director,
Illinois Department of Alcoholism and Substance Abuse, Chicago, IL
MOLLY JOEL COYE, * Executive Vice President,
Strategic Development, HealthDesk Corporation, Berkeley, CA
LYNNE M. DeGRANDE, President, DeGrande and Associates, Senior Consultant,
Employee Assistance Program, General Motors, Detroit, MI
RICHARD G. FRANK, Professor of Health Economics,
Department of Health Care Policy, Harvard Medical School, Boston, MA
JOHN E. FRANKLIN, JR., Associate Professor of Psychiatry,
Northwestern University Medical School, Chicago, IL
MICHAEL F. HOGAN, Director,
Ohio Department of Mental Health, Columbus, OH
DENNIS McCARTY, Director,
Substance Abuse Group, Institute for Health Policy, Heller Graduate School, Brandeis University, Waltham, MA
J. MICHAEL McGINNIS, Former Deputy Assistant Secretary for Health, Scholar-in-Residence,
Commission on Behavioral and Social Sciences and Education, National Academy of Sciences, Washington, DC (resigned from committee service, August 1996)
RHONDA J. ROBINSON-BEALE, Senior Associate Medical Director,
Coordinated Behavioral Health Management, Health Alliance Plan, Southfield, MI
ALEX R. RODRIGUEZ, Vice President and Medical Director,
National Account Consortium, Inc., Stamford, CT
STEVEN S. SHARFSTEIN, President, Medical Director, and Chief Executive Officer,
The Sheppard Pratt Health System, Baltimore, MD
DONALD L. SHUMWAY, Co-Director,
Self-Determination for People with Developmental Disabilities, Institute on Disability, University of New Hampshire, Durham, NH
CONSTANCE WEISNER, Senior Scientist,
Alcohol Research Group, Western Consortium for Public Health and School of Public Health, University of California at Berkeley, Berkeley, CA
Institute of Medicine Staff
MARGARET EDMUNDS, Study Director
CARRIE INGALLS, Research Associate
THOMAS WETTERHAN, Project Assistant/Research Assistant
AMELIA MATHIS, Project Assistant
TERRI SCANLAN, Administrative Assistant
EUGENE LEE, Student Intern
MOLLA DONALDSON, Senior Program Officer,
Division of Health Care Services
CONSTANCE PECHURA, Director,
Division of Neuroscience and Behavioral Health
*Member, Institute of Medicine.
Introducing a report that addresses such a complex and dynamic issue as managed behavioral health care is a daunting task. The charge to the Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care was to develop a framework to guide the development, use, and evaluation of performance indicators, accreditation standards, and quality improvement mechanisms. The framework could then be used to assist in the purchase and delivery of the most effective managed behavioral health care at the lowest appropriate cost for consumers of publicly and privately financed care.
There were numerous challenges in addressing this charge. The committee was operating in a rapidly changing environment in which multiple efforts by accreditation organizations, government agencies, consumer groups, and other interested parties were under way to develop report cards, performance indicators, and other measures of behavioral health care quality. The committee members chose to take an evidence-based approach to their task, but they found that the research base and the development of quality assurance and accreditation standards are far less advanced in behavioral health care than in other areas of health care.
Discussions among committee members clearly indicated a great diversity in opinions and experiences. The committee, however, believed that its charge to create a framework for assessing quality assurance and accreditation guidelines was best served by the development of recommendations broad enough to allow various stakeholder groups to make them more specific to their own needs and circumstances, as appropriate. This report fulfills this charge and provides a framework that will be useful and enduring. In addition, this report—possibly for the
first time—weaves together in a single place the many complex issues, concepts, and challenges involved in assuring quality in behavioral health care in a way that is accessible to a broad audience.
To accomplish its task, the committee began by developing the Statement of Principles included in Chapter 1 of the full report. These principles served to guide and unite the committee and are the outcome of intensive discussion and consensus-building across a rich diversity of views and perspectives.
As a primary care physician listening to the workshop presentations and deliberations, it was sometimes unclear to me whether or not mental health and substance abuse problems really presented unique challenges. For example, many of the presentations and discussions emphasized the importance of viewing mental health and substance abuse problems as chronic, relapsing conditions that do not differ significantly from other health problems, such as diabetes and heart disease. Other presentations, however, emphasized key differences, such as greater needs for integration of services, a large percentage of substance abuse problems being dealt with in the publicly funded Medicaid system, and the emergence of so-called “carve-out” companies providing behavioral health care, among other examples. Thus, the committee has tried throughout the report to underscore a critical distinction between the unique aspects of the structure of behavioral health care delivery and the nature of the disorders themselves, which are not unique, but can range from a single episode of illness to chronic, recurrent, and disabling conditions.
From early on in its deliberations, the committee was determined to be scrupulous in separating evidence-based research results from information based on current clinical strategies or best practices. Thus, the body of the report includes findings that were rigorously grounded in the research literature. However, the committee felt that this report could not go forward without expressing the strong clinical judgments that this is an exciting time in research, that rapid progress is being made in the diagnosis and treatment of behavioral health conditions, and that there is an increasing recognition of the importance of continuing care as a way to prevent or ameliorate relapses.
Although the report covers a wide range of topics and issues in this field, it might be useful to highlight some of the issues that the committee could not address fully and that will require ongoing consideration by federal and state agencies, as well as a number of other stakeholder groups. Four key areas seem to be important areas for further work by others. First, there are complex and often overlapping systems of regulation and accreditation, which result in different data requirements, specifications, and timetables. In addition, there are compelling needs to ensure the quality and integrity of the various measures used by many different organizations. This complexity presents real challenges to purchasers, consumers, providers, and practitioners of behavioral health care. This report describes the complexity and presents general recommendations to be considered by the variety of regulatory agencies and accreditation organizations (e.g., the utility
of external audits and quality improvement mechanisms). Whether or not the current system requires modification and how such modification should be approached, however, was beyond the scope of our work.
The second key area involves questions regarding the analysis and reporting of the many different types of quality assessment (e.g., report cards, patient satisfaction measures, and other evaluations) and, further, how to use such measures to develop accurate and appropriate case-mix and risk adjustment models. To address these questions, the committee believes that further development of analytical tools is necessary and that this evidence base needs to be expanded before detailed recommendations can be made. In addition, development of such tools will require collaboration among various components of the public and private sectors. The public- and private-sector entities involved might find it fruitful to consider ways to foster these collaborations.
Third, there is a general need to develop strategies to address the complexities of the Medicaid population, particularly as they relate to people with mental health and substance abuse problems and to the devolution of responsibility for this population from the federal government to the states. A comprehensive survey of the states and an analysis of the specific needs of the mental health and substance abuse segment of Medicaid-covered health care—and the variety of needs across states—were beyond the committee's charge. Yet, this theme was expressed at many of the committee's workshops and in its deliberations, and further work seems necessary to understand the complex needs of this population, particularly as they relate to strategies to integrate services across social services agencies and health care providers.
The fourth area relates to the variety of health care practitioners, often working simultaneously, who are involved in treating mental health and substance abuse problems. Clearly, tensions exist among some of these groups of practitioners, but there is also a great need to integrate care across the various disciplines when a patient is being treated by a team of practitioners. This situation is an excellent example of a systemic problem that contributes importantly to the fragmentation of services discussed in the report and that this committee could not solve. However, the variety of practitioners involved also presents special problems for measuring quality in managed behavioral health care, and these problems could benefit from further research to design specific approaches to handle the tensions and to address the need for integration of treatment services.
The entire health care system is changing rapidly, and behavioral health care is no exception. During the spring and summer months of 1996 when the committee met, Congress deliberated and then passed a compromise mental health parity bill, consumer groups challenged the capacity of accreditation organizations to measure quality, and researchers reported that psychotherapy had been found to produce changes in brain function similar to those seen with medications. While the report was being reviewed, President Clinton announced the formation of a federal advisory commission on the quality of health care. Thus,
the issues considered by the committee are timely and seem to reflect some fundamental policy questions, some of which will continue to be debated over the next decade and, possibly, longer.
As one who has been fortunate to participate on a number of Institute of Medicine committees, I must close with a personal statement. The subject matter, the committee and its generous participation in lively and informative meetings as well as in writing the report, and the IOM staff—particularly the study director, who kept the work on track and synthesized and balanced the multiple streams of input—have made this effort one of the most satisfying in which I have participated in the past 15 years.
Jerome Grossman, M.D., Chair
Committee on Quality Assurance and
Accreditation Guidelines for
Managed Behavioral Health Care
The committee would like to acknowledge the contributions of many individuals and organizations to the committee's work.
The committee expresses deep appreciation to all the individuals and groups who contributed to the public workshops. The speakers in the workshops were Don Austin, John Bartlett, Linda Bresolin, Ray Bridge, Catherine Brown, Reginald Cedar Face, Robert Cole, William Dennis Derr, Elizabeth Edgar, Robert Egnew, Michael Faenza, Daniel Fisher, Julia Puebla Fortier, Ann Froio, Donald Galamaga, Susan Goldman, Sybil Goldman, Sarah Gotbaum, Elizabeth Hadley, Laura Lee Hall, Judith Hines, Michael Jeffrey, Linda Kaplan, Randall Madry, Ron Manderscheid, David Mee-Lee, Raphael Metzger, Margaret O'Kane, Peter Panzarino, Mark Paris, Mark Parrino, Geoffrey Reed, Gwen Rubinstein, Paul Schyve, Tim Slaven, Golnar Simpson, Sarah Stanley, Tom Trabin, Robert Valdez, Rita Vandivort, and Grace Wang. Many individuals who were not speakers also participated by asking the workshop speakers questions, and they are listed in Appendix D.
The committee thanks Don Steinwachs and Thomas McLellan and his colleagues Mark Belding, James McKay, David Zanis, and Arthur Alterman for contributing their papers, which were used by the committee in preparing this report and which appear as Appendixes to this report.
The committee expresses appreciation to Don Detmer and Ed Perrin, who served, respectively, as liaisons to the Institute of Medicine (IOM) Board on Health Care Services and the National Research Council 's Committee on National Statistics (CNSTAT).
The committee is particularly grateful to the members of the liaison panel,
who raised many questions for the committee's consideration and helped to identify materials for the committee 's review. All of the members are listed in Appendix E. The members who were especially active in responding to requests for information were Linda Bresolin, Peggy Clark, Judith Emerson, Elizabeth Hadley, Judith Hines, Linda Kaplan, Anne Kilguss, Yvonne Lewis, Mark Paris, Mark Parrino, Clarke Ross, Gwen Rubinstein, Paul Schyve, Claire Sharda, Tom Trabin, Jeanne Trumble, Margaret Van Amringe, and Robert Valdez. Organizations that submitted written comments for the committee's review are listed in Appendix F.
The committee is grateful to several individuals who provided technical comments on preliminary drafts of sections of the report. They include Gary Chase, Peggy Clark, Denise Dougherty, Lynn Etheredge, Joe Frisino, Susan Goldman, Judith Katz-Leavy, Kathleen Lohr, Hal Luft, David Mactas, Ron Manderscheid, Clarke Ross, Hector Sanchez, Eugene Schoener, Paul Schyve, Claire Sharda, Lisa Simpson, and Tim Slaven.
The committee could not have accomplished its task without the insightful and tireless support of the study director, Margo Edmunds. Dr. Edmunds ' extraordinary skills in planning and managing the study, imaginative guidance of the committee's activities, and writing or editing numerous sections of the report provided an anchor for the committee throughout the study.
Other members of the IOM professional staff also provided invaluable help. Constance Pechura developed the idea for the study with the sponsor and provided guidance throughout, including descriptions of the IOM process and identification of resources and materials. Molla Donaldson attended committee meetings and reviewed draft sections of the report. Marilyn Field was responsive to many questions and reviewed draft sections of the report. Linda Bailey and Jane Durch helped to coordinate this study with the IOM study on public health performance monitoring, as did Jeff Koshel, study director for the CNSTAT effort on performance partnership grants.
The professional staff were supported by the efforts of Carrie Ingalls, research associate; Thomas Wetterhan, project assistant/research assistant; Amelia Mathis, project assistant; Terri Scanlan, administrator; and Eugene Lee, a summer student intern from the Massachusetts Institute of Technology. Other IOM and National Academy of Sciences staff who were helpful at a variety of stages include Carolyn Fulco, Carlos Gabriel, Kate-Louise Gottfried, Linda Kilroy, Lauren Leveton, Catharyn Liverman, Luis Nunez, Dan Quinn, Mary Lee Schneiders, and Andrea Solarz. During report review, Claudia Carl and Mike Edington provided valuable direction and technical assistance. The extensive commentary and suggestions made by the copy editor, Michael Hayes, are gratefully acknowledged.
Finally, support for this study was provided by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), and its three centers: the Center for Substance Abuse Treatment (CSAT), the Center for Mental Health Services (CMHS), and the Center for Substance Abuse Prevention (CSAP). David Mactas, the Director of CSAT,
the lead agency for the study, described the sponsor's goals for the study at the committee's first meeting. For their helpful responses to the staff's inquiries and requests throughout the study, the committee thanks Mady Chalk, Director of Managed Care Initiatives at CSAT and the government's project officer; Eric Goplerud, Director of SAMHSA's Managed Care Initiative; Jeff Buck, Acting Director of the CMHS Office of Policy and Planning; Nancy Kennedy, Managed Care Coordinator for CSAP; and Ron Manderscheid, Chief of the Survey Analysis Branch for the CMHS Division of State and Community Systems Development.
B Commissioned Paper: Can the Outcomes Research Literature Inform the Search for Quality Indicators in Substance Abuse Treatment?, A. Thomas McLellan, Mark Belding, James R. McKay, David Zanis, and Arthur I. Alterman
LIST OF TABLES, FIGURES, AND BOXES
Estimated Annual Prevalence of Behavioral Health Problems in the United States (Ages 15–54),
U.S. Health Insurance Data (in millions), 1992–1995,
Utilization of Services for Behavioral Health Problems,
Types of Managed Care Organizations,
Ecology of Consumer Protection: Current Context,
Estimated Annual Prevalence of Behavioral Health Problems in the United States (Ages 15–54),
Sample of Estimated Annual Prevalence of Behavioral Health Problems in Children and Adolescents,
Estimated Annual Prevalence of Drug Use Among Children and Adolescents, 1995,
Estimated Annual Economic Costs of Substance Abuse, 1990 (millions),
Estimated Annual Economic Costs of Mental Disorders by Disorder, 1990 (millions),
Estimated Annual Costs of Illness for Selected Diseases and Conditions (billions of dollars),
Uses of Funds for Mental Health and Substance Abuse: United States, 1990,
Profiles of U.S. Practitioners in Behavioral Health Care,
Medicaid and Medicare Total Populations and Number Enrolled in Managed Care (MC) Plans, 1991–1995,
Types of Care in Substance Abuse Treatment,
Mental Health Treatment Settings,
Comparison of Public and Private Sectors of Care in Mental Health,
“Wraparound” and “Enabling” Services,
Cross-Comparison of Managed Behavioral Health Care Performance Indicators,
Cross-Comparison of Selected Accreditation Organizations in Managed Behavioral Health Care,
Selected Regulatory and Consumer Protection Models,
Desirable Attributes of a Quality Assurance Program,
Substance Abuse-Specific Outcomes Objectives by Level of Treatment,
General Outcomes Measures for Substance Abuse and Mental Health Populations,
Performance Indicators Based on Outcomes Research,
Number of HMO enrollees, 1976–1995,
Framework for quality assessment,
Model for research on the quality of mental health services,
Terminology Used in This Report,
National Demonstration Project on Quality Improvement in Health Care: Applications and Implementation,
The Case for Treatment of Mental Disorders and Addiction,
Historical Perspective on the Development of Behavioral Health Systems,
Sample Access Standards and Measures for Behavioral Health Care,
Accreditation Association for Ambulatory Health Care
American Academy of Addiction Psychiatry
American Academy of Family Physicians
American Association of Health Plans
American Association of Marriage and Family Therapy
Association of Asian Pacific Community Health Organizations
American Bar Association
American Board of Medical Specialties
American Board of Psychiatry and Neurology
American College of Preventive Medicine
Alcohol, Drug Abuse, and Mental Health Administration
Aid to Families with Dependent Children
Agency for Health Care Policy and Research
Acquired Immune Deficiency Syndrome
American Medical Association
American Managed Behavioral Healthcare Association
American Methadone Treatment Association
American Nurses Association
American Public Welfare Association
American Society of Addiction Medicine
Addiction Severity Index
Association of State and Territorial Health Officials
certified addiction counselor
Rehabilitation Accreditation Commission, formerly the Commission on Accreditation of Rehabilitation Facilities
Child and Adolescent Service System Program
Committee on the Costs of Medical Care
Centers for Disease Control and Prevention
Civilian Health and Medical Program of the Uniformed Services
Civilian Health and Medical Program of the Veterans Administration
Community Mental Health Centers
Center for Mental Health Services
Committee on National Statistics, part of the National Research Council
Council on Accreditation of Services for Families and Children
Computerized Needs-Oriented Quality Measurements Evaluation System
National Coalition of Hispanic Health and Human Services Organizations
continuous quality improvement
California Society on Addiction Medicine
Center for Substance Abuse Prevention
Center for Substance Abuse Treatment
Community Support Program
Department of Health and Human Services
Department of Defense
Drug Use Forecasting
employee assistance program
Employee Assistance Professional Association
epidemiologic catchment area
early and periodic screening, diagnosis, and treatment
Employee Retirement Income Security Act
Foundation for Accountability
Food and Drug Administration
Health Care Financing Administration
Health Plan Employer Data and Information Set, developed by NCQA
Health Insurance Association of America
human immunodeficiency virus
health maintenance organization
Health Resources and Services Administration
Institute for Behavioral Healthcare
Indian Health Service
Institute of Medicine
Independent Practice Association
Joint Commission on Accreditation of Hospitals
Joint Commission on Accreditation of Healthcare Organizations
managed behavioral health care
managed behavioral health care organization
motivational enhancement therapy
Mental Health Statistics Improvement Program
Medical Outcomes Study, conducted by the RAND Corporation
mentally retarded and developmentally disabled
management services organization
National Association of Alcoholism and Drug Abuse Counselors
National Association of County and City Health Officials
National Association of County Managed Behavioral Health Directors
National Association of Health Data Organizations
National Association of Insurance Commissioners
National Alliance for the Mentally Ill
National Association for Research on Schizophrenia and Depression
National Association of State Alcohol and Drug Abuse Directors
National Association of State Mental Health Program Directors
National Association of Social Workers
National Business Coalition on Health
National Center for Health Statistics
National Committee for Quality Assurance
National Drug and Alcohol Treatment Unit Survey
National Depressive and Manic Depressive Association
National Empowerment Center
National Federation of Societies for Clinical Social Work
National Governors' Association
National Institute on Alcohol Abuse and Alcoholism
National Institute on Drug Abuse
National Institutes of Health
National Institute of Mental Health
National Mental Health Association
National Treatment Improvement Evaluation Study
Program in Assertive Community Treatment
Pacific Business Group on Health
Performance-Based Measures for Managed Behavioral Healthcare Program, developed by AMBHA
physician hospital organization
Public Health Service
preferred provider organization
Research Triangle Institute
Science Applications International Corporation
Substance Abuse and Mental Health Services Administration
Special Action Office for Drug Abuse Prevention
Securities and Exchange Commission
State Mental Health Representatives for Children and Youth
Social Security Disability Insurance
Supplemental Security Income
Treatment Alternatives for Special Clients, formerly Treatment Alternatives to Street Crime
Therapeutic Communities of America
Treatment Episode Data Set
Uniform Facility Data Survey
Utilization Review Accreditation Commission
University of Rhode Island Change Assessment
Department of Veterans Affairs, formerly Veterans Administration
Washington Business Group on Health
World Federation for Mental Health