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

MANAGING MANAGED CARE

QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH

Margaret Edmunds, Richard Frank, Michael Hogan, Dennis McCarty, RhondaRobinson-Beale, and Constance Weisner, Editors

Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care

Division of Neuroscience and Behavioral Health

Division of Health Care Services

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1997

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

NATIONAL ACADEMY PRESS
2101 Constitution Avenue, N.W. Washington, DC 20418

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.

p. cm

Includes index.

ISBN 0-309-05642-X

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]

RC480.5.M325 1997

362.2′00973—dc21

DNLM/DLC

for Library of Congress

97-20004

CIP

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.

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

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,

Washington, DC

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

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

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.

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

Preface

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

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

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

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

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,

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

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

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

Acknowledgments

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,

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

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,

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

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.

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

 3

 

CHALLENGES IN DELIVERY OF BEHAVIORAL HEALTH CARE

 

76

   

 Extent and Impact of Behavioral Health Problems,

 

77

   

 The Role of Primary Care,

 

87

   

 Special Issues for Quality in Behavioral Health Care,

 

89

   

 Developments in the Private Sector,

 

93

   

 Quality and Consumer Protection Challenges,

 

95

   

 Variability at the State Level,

 

95

   

 Historical Perspective on Systems,

 

96

   

 Summary: System Integration,

 

115

 4

 

STRUCTURE

 

122

   

 Practitioner Issues,

 

123

   

 Medicaid,

 

128

   

 Medicare,

 

130

   

 Substance Abuse Service Systems,

 

131

   

 Mental Health Treatment,

 

135

   

 Wraparound Services,

 

136

   

 The Managed Behavioral Health Care Industry,

 

141

   

 Workplace Services,

 

142

   

 U.S. Department of Defense and U.S. Department of Veterans Affairs,

 

148

   

 Care and Services for Children and Adolescents,

 

152

   

 Care and Services for Seniors,

 

156

   

 Indian Health Service,

 

157

   

 Cultural Competence,

 

159

   

 Rural Health and Managed Care,

 

162

   

 Summary of Structural Issues,

 

163

 5

 

ACCESS

 

168

   

 Importance of Assessing Access,

 

169

   

 Measures of Access,

 

171

   

 Need and Access,

 

174

   

 Needs of Special Populations,

 

175

   

 Measuring Access to Services Within Managed Care Organizations,

 

178

   

 Summary,

 

179

 6

 

PROCESS

 

184

   

 Quality and Accountability,

 

184

   

 Quality Management in Behavioral Health Care,

 

189

   

 Performance Measurement in the Public Sector,

 

199

   

 Accreditation,

 

203

   

 Information Infrastructure for Quality Measurement,

 

217

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

 Role of Government in Quality Assurance,

 

218

   

 Summary,

 

223

 7

 

OUTCOMES

 

226

   

 Definitions of Success,

 

226

   

 General and Specific Measures of Outcomes,

 

228

   

 Links Among Structure, Process, and Outcomes,

 

232

   

 Performance Indicators as Outcomes Measures,

 

233

   

 Efficacy and Effectiveness,

 

234

   

 Outcomes and Quality Improvement,

 

234

   

 Criteria for Evaluating Outcomes Measures,

 

235

   

 Summary,

 

238

 8

 

FINDINGS AND RECOMMENDATIONS

 

241

   

1. Structure and Financing,

 

242

   

2. Accreditation,

 

243

   

3. Consumer Involvement,

 

247

   

4. Cultural Competence,

 

248

   

5. Special Populations,

 

249

   

6. Research,

 

249

   

7.  Workplace,

 

250

   

8. Wraparound Services,

 

251

   

9. Children and Adolescents,

 

251

   

10. Clinical Practice Guidelines,

 

252

   

11. Primary Care,

 

253

   

12.  Ethical Concerns,

 

254

 

 

GLOSSARY

 

255

 

 

APPENDIXES

 
   

A Committee Biographies

 

263

   

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

 

271

   

C Commissioned Paper: Consumer Outcomes and Managed Behavioral Health Care: Research Priorities, Donald M. Steinwachs

 

312

   

D Public Workshop Agendas and Participants

 

336

   

E Liaison Panel Members to the Committee

 

349

   

F OrganizationsThat Submitted Written Materials to the Committee

 

355

 

 

INDEX

 

357

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

LIST OF TABLES, FIGURES, AND BOXES

TABLES

 Table 1.1

 

Estimated Annual Prevalence of Behavioral Health Problems in the United States (Ages 15–54),

 

16

 Table 1.2

 

U.S. Health Insurance Data (in millions), 1992–1995,

 

29

 Table 1.3

 

Utilization of Services for Behavioral Health Problems,

 

30

 Table 2.1

 

Types of Managed Care Organizations,

 

43

 Table 2.2

 

Ecology of Consumer Protection: Current Context,

 

55

 Table 3.1

 

Estimated Annual Prevalence of Behavioral Health Problems in the United States (Ages 15–54),

 

78

 Table 3.2a

 

Sample of Estimated Annual Prevalence of Behavioral Health Problems in Children and Adolescents,

 

79

 Table 3.2b

 

Estimated Annual Prevalence of Drug Use Among Children and Adolescents, 1995,

 

80

 Table 3.3

 

Estimated Annual Economic Costs of Substance Abuse, 1990 (millions),

 

81

 Table 3.4

 

Estimated Annual Economic Costs of Mental Disorders by Disorder, 1990 (millions),

 

82

 Table 3.5

 

Estimated Annual Costs of Illness for Selected Diseases and Conditions (billions of dollars),

 

83

 Table 3.6

 

Uses of Funds for Mental Health and Substance Abuse: United States, 1990,

 

92

 Table 4.1

 

Profiles of U.S. Practitioners in Behavioral Health Care,

 

124

 Table 4.2

 

Medicaid and Medicare Total Populations and Number Enrolled in Managed Care (MC) Plans, 1991–1995,

 

130

 Table 4.3

 

Types of Care in Substance Abuse Treatment,

 

132

 Table 4.4

 

Mental Health Treatment Settings,

 

137

 Table 4.5

 

Comparison of Public and Private Sectors of Care in Mental Health,

 

138

 Table 4.6

 

“Wraparound” and “Enabling” Services,

 

140

 Table 6.1

 

Cross-Comparison of Managed Behavioral Health Care Performance Indicators,

 

192

 Table 6.2

 

Cross-Comparison of Selected Accreditation Organizations in Managed Behavioral Health Care,

 

206

 Table 6.3

 

Selected Regulatory and Consumer Protection Models,

 

220

 Table 6.4

 

Desirable Attributes of a Quality Assurance Program,

 

223

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

 Table 7.1

 

Substance Abuse-Specific Outcomes Objectives by Level of Treatment,

 

229

 Table 7.2

 

General Outcomes Measures for Substance Abuse and Mental Health Populations,

 

230

 Table 7.3

 

Performance Indicators Based on Outcomes Research,

 

233

FIGURES

 Figure 1.1

 

Number of HMO enrollees, 1976–1995,

 

32

 Figure 1.2

 

Framework for quality assessment,

 

34

 Figure 7.1

 

Model for research on the quality of mental health services,

 

231

BOXES

 Box 1.1

 

Terminology Used in This Report,

 

23

 Box 2.1

 

National Demonstration Project on Quality Improvement in Health Care: Applications and Implementation,

 

63

 Box 3.1

 

The Case for Treatment of Mental Disorders and Addiction,

 

86

 Box 3.2

 

Historical Perspective on the Development of Behavioral Health Systems,

 

97

 Box 5.1

 

Sample Access Standards and Measures for Behavioral Health Care,

 

172

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

Acronyms

AA

Alcoholics Anonymous

AAAHC

Accreditation Association for Ambulatory Health Care

AAAP

American Academy of Addiction Psychiatry

AAFP

American Academy of Family Physicians

AAHP

American Association of Health Plans

AAMFT

American Association of Marriage and Family Therapy

AAPCHO

Association of Asian Pacific Community Health Organizations

ABA

American Bar Association

ABMS

American Board of Medical Specialties

ABPN

American Board of Psychiatry and Neurology

ACPM

American College of Preventive Medicine

ADAMHA

Alcohol, Drug Abuse, and Mental Health Administration

AFDC

Aid to Families with Dependent Children

AHCPR

Agency for Health Care Policy and Research

AIDS

Acquired Immune Deficiency Syndrome

AMA

American Medical Association

AMBHA

American Managed Behavioral Healthcare Association

AMTA

American Methadone Treatment Association

ANA

American Nurses Association

APWA

American Public Welfare Association

ASAM

American Society of Addiction Medicine

ASI

Addiction Severity Index

ASTHO

Association of State and Territorial Health Officials

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

CAC

certified addiction counselor

CARF

Rehabilitation Accreditation Commission, formerly the Commission on Accreditation of Rehabilitation Facilities

CASSP

Child and Adolescent Service System Program

CCMC

Committee on the Costs of Medical Care

CD

chemical dependency

CDC

Centers for Disease Control and Prevention

CHAMPUS

Civilian Health and Medical Program of the Uniformed Services

CHAMPVA

Civilian Health and Medical Program of the Veterans Administration

CMHC

Community Mental Health Centers

CMHS

Center for Mental Health Services

CNSTAT

Committee on National Statistics, part of the National Research Council

COA

Council on Accreditation of Services for Families and Children

CONQUEST

Computerized Needs-Oriented Quality Measurements Evaluation System

COSSHMO

National Coalition of Hispanic Health and Human Services Organizations

CQI

continuous quality improvement

CSAM

California Society on Addiction Medicine

CSAP

Center for Substance Abuse Prevention

CSAT

Center for Substance Abuse Treatment

CSP

Community Support Program

DHHS

Department of Health and Human Services

DOD

Department of Defense

DUF

Drug Use Forecasting

EAP

employee assistance program

EAPA

Employee Assistance Professional Association

ECA

epidemiologic catchment area

EPSDT

early and periodic screening, diagnosis, and treatment

ERISA

Employee Retirement Income Security Act

FACCT

Foundation for Accountability

FDA

Food and Drug Administration

FFS

fee-for-service

HCFA

Health Care Financing Administration

HEDIS

Health Plan Employer Data and Information Set, developed by NCQA

HIAA

Health Insurance Association of America

HIV

human immunodeficiency virus

HMO

health maintenance organization

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

HRSA

Health Resources and Services Administration

IBH

Institute for Behavioral Healthcare

IHS

Indian Health Service

IOM

Institute of Medicine

IPA

Independent Practice Association

JCAH

Joint Commission on Accreditation of Hospitals

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

LAAM

levo-alpha-acetylmethadol

MBHC

managed behavioral health care

MBHO

managed behavioral health care organization

MC

managed care

MET

motivational enhancement therapy

MHSIP

Mental Health Statistics Improvement Program

MOS

Medical Outcomes Study, conducted by the RAND Corporation

MR/DD

mentally retarded and developmentally disabled

MSO

management services organization

NA

Narcotics Anonymous

NAADAC

National Association of Alcoholism and Drug Abuse Counselors

NACCHO

National Association of County and City Health Officials

NACMBHD

National Association of County Managed Behavioral Health Directors

NAHDO

National Association of Health Data Organizations

NAIC

National Association of Insurance Commissioners

NAMI

National Alliance for the Mentally Ill

NARSD

National Association for Research on Schizophrenia and Depression

NASADAD

National Association of State Alcohol and Drug Abuse Directors

NASMHPD

National Association of State Mental Health Program Directors

NASW

National Association of Social Workers

NBCH

National Business Coalition on Health

NCHS

National Center for Health Statistics

NCQA

National Committee for Quality Assurance

NDATUS

National Drug and Alcohol Treatment Unit Survey

NDMDA

National Depressive and Manic Depressive Association

NEC

National Empowerment Center

NFSCSW

National Federation of Societies for Clinical Social Work

NGA

National Governors' Association

NIAAA

National Institute on Alcohol Abuse and Alcoholism

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

NIDA

National Institute on Drug Abuse

NIH

National Institutes of Health

NIMH

National Institute of Mental Health

NMHA

National Mental Health Association

NTIES

National Treatment Improvement Evaluation Study

PACT

Program in Assertive Community Treatment

PBGH

Pacific Business Group on Health

PERMS

Performance-Based Measures for Managed Behavioral Healthcare Program, developed by AMBHA

PHO

physician hospital organization

PHS

Public Health Service

PO

physician organization

POS

point-of-service plan

PPO

preferred provider organization

RTI

Research Triangle Institute

SAIC

Science Applications International Corporation

SAMHSA

Substance Abuse and Mental Health Services Administration

SAODAP

Special Action Office for Drug Abuse Prevention

SEC

Securities and Exchange Commission

SMHRCY

State Mental Health Representatives for Children and Youth

SSDI

Social Security Disability Insurance

SSI

Supplemental Security Income

TASC

Treatment Alternatives for Special Clients, formerly Treatment Alternatives to Street Crime

TB

tuberculosis

TCA

Therapeutic Communities of America

TEDS

Treatment Episode Data Set

UFDS

Uniform Facility Data Survey

UM

utilization management

UR

utilization review

URAC

Utilization Review Accreditation Commission

URICA

University of Rhode Island Change Assessment

VA

Department of Veterans Affairs, formerly Veterans Administration

WBGH

Washington Business Group on Health

WFMH

World Federation for Mental Health

Page xxii Cite
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MANAGING MANAGED CARE

QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH

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Managing Managed Care: Quality Improvement in Behavioral Health Get This Book
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Managed care has produced dramatic changes in the treatment of mental health and substance abuse problems, known as behavioral health. Managing Managed Care offers an urgently needed assessment of managed care for behavioral health and a framework for purchasing, delivering, and ensuring the quality of behavioral health care. It presents the first objective analysis of the powerful multimillion-dollar accreditation industry and the key accrediting organizations.

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

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

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

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