With great speed and a considerable amount of controversy, managed care has produced dramatic changes in American health care. At the end of 1995, 161 million Americans—more than 60 percent of the total population—belonged to some form of managed health care plan. Health maintenance organizations (HMOs), preferred provider organizations, point-of-service plans, and other forms of managed care networks differ in organizational structures, types of practitioners and services, access strategies, payment for practitioners, and other features. Their goals, however, are similar: to control costs through improved efficiency and coordination, to reduce unnecessary or inappropriate utilization, to increase access to preventive care, and to maintain or improve the quality of care.
The movement into managed care has been especially rapid for treatment of ubstance abuse (alcohol and drug) problems, also known as behavioral health. Behavioral health problems are common: every year, an estimated 52 million Americans have some kind of mental health or substance abuse problem. At the end of 1995, the behavioral health benefits of nearly 142 million people were managed, with 124 million in specialty managed behavioral health programs and 16.9 million with benefits managed within an HMO.
Both private-sector employers and public-sector agencies (Medicaid and state mental health and substance abuse authorities) have turned to managed behavioral health care companies to control costs and improve quality and access for mental health and substance abuse care. Purchasers share with responsible managed care organizations a unifying goal of a more responsive health care delivery system, one that is both more efficient and more effective. Several approaches have been developed to assess the quality of care: accreditation, licensing and
certification, credentialing and privileging, and the use of practice guidelines, performance measures, report cards, and other means. Thus, the array of quality improvement approaches resembles a complex patchwork, reflecting the fragmented system that delivers the care and the wide variety of evidence and opinions about quality of care.
In the spring of 1995, the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA), asked the Institute of Medicine to convene an expert committee that would consider issues related to quality assurance and accreditation in managed behavioral health care. The charge to the committee 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. The 17 members of the committee were chosen for their expertise with national accreditation processes and procedures, public and private managed care organizations, employee assistance 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 who were family members of consumers.
The committee met five times between February and July 1996. To gather information to assist in their deliberations, the committee convened two public workshops. 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.
Many interested parties are using a variety of methods to protect consumers and improve the quality of care in this environment of rapid change. The charge and focus of this committee is on managed care, although the committee recognizes that other issues such as licensure of practitioners and state inspection and certification of provider agencies play critical roles in consumer protection. Furthermore, in its focus on managed care, the committee has been particularly concerned with two prominent strategies: accreditation of managed care entities and the use of performance measurements. At the same time, it has considered complementary strategies that can aid in consumer protection and quality improvements, such as consumer choice of health plans, better integration of research and practice, and especially, reducing the flaws in the organization of behavioral health care.
To provide a framework for the study, the committee adapted the work of
Avedis Donabedian, who has described three interrelated ways to understand and measure quality: structure, process, and outcomes. Structural measures of quality include the types of services available, the qualifications of practitioners, staffing patterns, adherence to building and other codes, and other administrative information. Process measures of quality focus on procedures and courses of treatment, such as the numbers of individuals served; on the appropriateness of the care; and on ongoing efforts to maintain quality, such as practice guidelines and continuous quality improvement activities. Outcome measures of quality include health status changes after treatment and consumer satisfaction with the care provided, as well as short-term or intermediate outcomes.
CHALLENGES TO DELIVERY OF BEHAVIORAL HEALTH CARE
The most unusual aspect of the care and financing system for behavioral health care services is the presence of a distinct and substantial publicly managed care system that serves as a safety net. Thus, public services are available for those with public insurance as well as for those with private insurance. Public services are funded through a large number of categorical programs administered by different agencies, creating both duplication and gaps in service, and these programs almost always have different eligibility requirements. Fragmentation in funding leads to fragmented service delivery.
Another challenge is that much of behavioral health care, perhaps as many as half of all episodes of care, is provided in primary care settings, not in specialty programs. Despite clinical practice guidelines, continuing education courses, and other training programs, primary care providers tend to underdiagnose depression, substance abuse, and other behavioral health problems. This is changing, but there is a great need to improve the quality of behavioral health care delivered in primary care settings and to better coordinate the care delivered in primary care and specialty sectors.
In addition, a significant portion of the public care system for individuals with the most disabling conditions extends beyond health care services to rehabilitative and support services, including housing, job counseling, literacy, and other programs. The coordination of these services requires collaborative and cooperative relationships among many agencies, including public health, mental health, social services, housing, education, criminal justice, and others. Most of these services are not covered by private insurance and have not been developed by most private behavioral health care companies.
The dynamics of the three interrelated sectors—privately funded primary and specialty care and public systems—are complex and also highly idiosyncratic from state to state, community to community, and plan to plan. Any approach to reform of behavioral health care services or to the problem of accountability must reckon with these factors, which are not simultaneously present in any other substantial sector of the health care system.
Analysis of the structure of the behavioral health care service system requires a review of the public and private service systems for both substance abuse and mental illness. The behavioral health care delivery system involves a complex combination of public and private financing as well as public and private practitioners of care. Public-sector services are financed either with state and federal appropriations or through Medicaid and Medicare coverage and are delivered in a wide variety of treatment settings. Private systems of care have different structures but coexist and often overlap with public sector services. Workplace service systems (e.g., employee assistance programs) and managed behavioral health care strategies have had a stronger influence in the private sector, but they are beginning to develop linkages with public agencies.
Federally supported service systems developed by the U.S. Department of Defense and the U.S. Department of Veterans Affairs share characteristics of both the private- and public-sector systems of care but represent separate and distinct service systems. In addition, service systems also exist for distinct populations: children, seniors, and Native Americans. The existence of a large number of independent service delivery systems serving different populations through different funding streams complicates the assessment of quality and can inhibit the development and implementation of comprehensive standards to improve the quality of care.
Managed behavioral health care organizations define access and accessibility using utilization (e.g., penetration rates and the use of specific services) and telecommunication (e.g., on-hold time and call abandonment rates) measures. Purchasers, however, may prefer to view access more broadly and include reductions in barriers to care and improvements in benefits (e.g., reductions in copayments, increases in hours of service, reductions in travel time, and expanded eligibility for specific services or populations).
The nature of managed care and the nature of mental illness and substance abuse combine to make access a most critical issue. Well-developed public and private health care and behavioral health care plans will promote access to mental health and substance abuse services. Enrollees that access care promptly and early in their illness episode may require less intensive care, and with appropriate continuing support they may be less likely to experience relapses.
Measures of access, however, should go beyond telephone answering time and begin to reflect the real and perceived barriers to care including cultural differences, geographic distance, inconvenient locations and times, and care that is less intensive than needed. Moreover, the purchasers of health care plans and the plan administrators must begin to assess the adequacy of their current access. In
formation on the ambient level of need in the health plan is required to truly assess the adequacy of the plan in meeting the demand and need for care.
In broad terms, measurement of the quality of health care is driven by different forces in the private and public sectors. In the private sector, quality measurement is a reflection of the requirements of the accreditation process and is increasingly a response to the demands of employers and other purchasers through contracting, report cards, and other means. In the public sector, performance measurement is the primary tool of accountability for spending public funds on health care.
Many methods are used to assess quality: accreditation, licensing and certification, credentialing, auditing, peer review, performance monitoring, contracts, clinical standards and guidelines, consumer satisfaction surveys, and report cards. Some private payers have developed their own standards for HMOs and other managed care organizations that provide care and are also urging contracted organizations to collect and publicly report information on their performance. Public agencies are also developing performance standards.
The interest in quality is reinforced by consumer demand and empowerment, professional ethics, legal and regulatory interpretation of citizens ' rights, and attempts by businesses to satisfy and keep customers in a competitive health care marketplace. For public purchasers who are accountable for public funds, it is important to demonstrate that health care has good value and is worth the investment.
In the committee's view, outcomes research is vitally important to improve the base of evidence related to treatment effectiveness. Outcomes research is needed to provide explicit direction in identifying performance indicators associated with good outcomes for different patient characteristics, types of treatment programs, and types of managed care organizations. In their current forms, performance indicators are not specific for particular treatment characteristics (organizational and clinical), and there is a lack of consensus of clinical judgment with regard to the relationship to outcome.
Public interest in quality of care is keen, and purchasers are not waiting for conclusive outcomes research to help them make decisions on the value and effectiveness of different managed care options. However, much needs to be done to link findings from outcomes research with the development of practice guidelines, performance measures, and accreditation approaches. Future methods of quality assessment will need to bridge the domains of research and practice and will need to
provide more direct input into the development of accreditation and other assessment strategies.
HIGHLIGHTS OF FINDINGS AND RECOMMENDATIONS
Federal, state, and local governments, accreditation organizations, managed care organizations, purchaser coalitions, consumers groups, professional organizations, and the media are actively involved in quality assessment. Some of these efforts are collaborative, but some are competitive. Overall, the picture is incomplete, inconsistent, and inadequate for making truly informed health care purchasing decisions. To those who are responsible for purchasing care, the absence of consensus on quality measurements is a challenge.
The committee developed a set of findings and recommendations in 12 areas: structure and financing; accreditation; consumer involvement; cultural competence; special populations; research; workplace; wraparound services; children and adolescents; clinical practice guidelines; primary care; and ethical concerns. Chapter 8 of this report contains all of the findings and recommendations. Only the recommendations are presented in this Summary.
1. STRUCTURE AND FINANCING
1.1 The reform of systems of care financed by states and counties must: (1) recognize current aspects of private health care in those states and counties and (2) consider the design and development of mechanisms to inhibit cost-shifting.
1.2 Payment arrangements that reduce incentives to underserve individuals with behavioral health conditions should be encouraged.
1.3 The reform of state and local systems through the use of managed care should incorporate a recognition of and responsiveness to the unique needs of consumers served by public systems.
1.4 Accreditation organizations, when appropriate, and purchasers should develop criteria and guidelines that: (1) recognize and measure dumping, skimming, and cost-shifting; and (2) specify rewards for organizations, groups, and individuals that provide appropriate care and penalties for those that do not.
1.5 Purchasers should ensure continuity of care for consumers when managed care contracts are awarded to different provider organizations.
Monitoring Quality of Care
2.1 Public and private purchasers, consumers, providers, practitioners, behavioral health care plans, and accreditation organizations should continue to monitor and assess the quality of care in the following ways:
2.1.1 Quality improvement should be a priority, and principles and methods of improving quality should be adopted.
2.1.2 Accreditation and review processes must be reliable and valid and must be continuously reviewed and improved.
2.1.3 Domains relevant to the effective treatment and prevention of behavioral health problems must be emphasized in accreditation processes. These include practitioner training, consumer education, improvements in consumer self-care, and the presence of a continuum of services, including wraparound services such as housing assistance, child care, and transportation.
2.1.4 Accreditation processes must focus on areas of managed care in which there may be a risk of quality problems: (1) variability in utilization review; (2) inconsistent or inappropriate precertification processes; (3) vulnerable groups and those who are unfamiliar with managed care processes; and (4) conditions that occur frequently and are treated by many practitioners, giving opportunities for variation in treatment practices.
2.1.5 Performance measures must be relevant to treatment processes and outcomes.
2.1.6 Data must have demonstrable integrity. External, independent audits can help to validate data quality.
2.1.7 Stakeholder consensus and consumer satisfaction measures must be included in the tools used to monitor quality of care.
2.1.8 Outcomes measures should increasingly be based on evidence from research.
2.2 Quality of care should be clearly addressed in contracts between purchasers and providers.
2.2.1 When plans contract or subcontract for the management and delivery of behavioral health care services (e.g., health maintenance organizations contracting with carved-out managed behavioral health care firms), purchasers can benefit from independent audits of the contractor regarding the level of adherence to prespecified standards of performance with respect to quality.
2.2.2 Purchasers can benefit from carefully constructed contract lan
guage to ensure the quality, accessibility, and effectiveness of behavioral health plans. Contracts should also specify the ways in which the quality and effectiveness standards will be monitored and enforced, including conditions for applying positive incentives for meeting or exceeding the standards and penalties for substandard performance.
Role of the Federal Government
2.3 The federal government should play a role in consumer protection in managed care by:
2.3.1 Promoting the improvement and use of performance measures for managed care.
2.3.2 Monitoring and studying the use and effectiveness of quality assurance, accreditation, performance measures, and outcomes measurements.
2.3.3 Establishing minimum standards for accreditation organizations to achieve deemed status (i.e., when the government, in its role as purchaser of managed care services, accepts accreditation as a measure of adequate quality and consumer protection).
Role of State Governments
2.4 The role of state governments in consumer protection should include the following:
2.4.1 Support the development of consumer protection standards for managed behavioral health care by state mental health and substance abuse agencies, state Medicaid agencies, state insurance departments, state licensing boards, state hospitals, and state child welfare agencies. State consumer groups, such as the chapters of the National Mental Health Association (NMHA), National Depressive and Manic Depressive Association (NDMDA), National Association for Research on Schizophrenia and Depression (NARSD), and National Alliance for the Mentally Ill (NAMI), should be included in the development of standards.
2.4.2 Maintain the minimum necessary regulatory standards, including the use of accreditation, to assure consumer protection while encouraging innovations in the delivery of care.
2.4.3 Consider offering deemed status to specific accreditation organizations that meet state-defined standards for quality of managed behavioral health care services.
Roles of All Levels of Government
2.5 Both federal and state governments should:
2.5.1 Encourage the development of report cards or other similar materials to help inform consumers and families about specific plans and the quality of care.
2.5.2 Include all stakeholders (accreditation organizations, employers, state agencies, consumers, families, providers, and practitioners) in the development, implementation, and use of standards.
2.6 Because managed care methods are increasingly applied to public systems, accreditation bodies and managed care plans should evaluate the inclusion of a variety of types of practitioners, including substance abuse counselors and mental health workers, in provider panels; collect information on practitioner effectiveness; and remove any practitioners from networks only for performance reasons (e.g., poor outcomes and poor consumer satisfaction).
2.6.1 The Substance Abuse and Mental Health Services Administration (SAMHSA), Agency for Health Care Policy and Research (AHCPR), Health Resources and Services Administration (HRSA), and National Institutes of Health (NIH) (National Institute on Alcohol Abuse and Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]) should cosponsor research to evaluate the components of treatment that are most effective in providing behavioral health care, including strategies used by psychiatrists, psychologists, social workers, counselors, and primary care practitioners.
2.6.2 The Substance Abuse and Mental Health Services Administration (SAMHSA), Agency for Health Care Policy and Research (AHCPR), Health Resources and Services Administration (HRSA), and National Institutes of Health (NIH) (National Institute on Alcohol Abuse and Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]) should cosponsor research 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
3.1 Health care purchasers must be responsive to consumers and families and should develop means of ensuring their meaningful participation in treat
ment decisions, measurement of satisfaction, and measurement 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 measures should include all stakeholders, including consumers, families, practitioners, and researchers.
4. CULTURAL COMPETENCE
4.1 Health plans and programs should be responsive to community demographics and to the cultural needs of the populations that they serve.
4.2 Practitioners of alternative and innovative treatments without an accepted research base should not arbitrarily be excluded from health plans. If these treatments are used, their effectiveness should be studied so that standards of quality improvement can be developed.
4.3 Health plans should have an explicit mechanism for evaluating new and innovative techniques and types of practitioners.
5. SPECIAL POPULATIONS
5.1 Research is needed to identify incentives for plans to serve vulnerable populations. The Substance Abuse and 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 evaluate the needs of those groups through reviews of research literature, consumer surveys, and other appropriate mechanisms.
5.3 All plans should meet the same core standards. Supplemental standards can be developed for special populations, whether they are in stand-alone programs or in mainstream plans, for example, for a child of an employed person with family coverage.
6.1 The committee recommends continued development of collaborative
health services research in substance abuse and mental health, and encourages the Agency for Health Care Policy and Research (AHCPR), Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH) (National Institute on Alcohol Abuse and Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], and the National Institute of Mental Health [NIMH]), and Substance Abuse and Mental Health Services Administration (SAMHSA) to maintain, to evaluate, and, where necessary, to expand programs and 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 practitioner types and for consumers with different needs.
6.3 Researchers should become more involved in studies carried out in managed care organizations and community-based settings and in other clinical outcomes research used to develop standards and performance measures.
7.1 Employers should investigate the benefits of wellness activities, employee assistance programs, and health risk reduction initiatives that enhance prevention, early intervention, access, and treatment adherence for health and behavioral health problems.
7.2 The Substance Abuse and Mental Health Services Administration (SAMHSA) should identify models of successful behavioral health programs in the workplace and increase public awareness of these models.
8. WRAPAROUND SERVICES
8.1 Further research is needed to prioritize the essential components of a treatment regimen that can address adequately the complex behavioral aspects of recovery from alcoholism and other drug addictions.
8.2 To maximize full functioning for individuals with severe and persistent mental illness, and to optimize conditions supporting recovery for individuals with chronic substance abuse problems, wraparound services such as social welfare, housing, vocational, and rehabilitative services should be available and should be coordinated.
8.3 For children and adolescents with severe emotional disturbances, edu-
cational and home environment-family support services should be coordinated and integrated with mental health care.
8.4 Accreditation systems must address the social and rehabilitative aspects as well as the medical aspects of comprehensive treatment for addiction and severe and persistent mental illness.
9. CHILDREN AND ADOLESCENTS
9.1 The Substance Abuse and Mental Health Services Administration (SAMHSA), National Institutes of Health (NIH) (National Institute on Alcoholism and Alcohol Abuse [NIAAA], National Institute on Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]), and the Health Research and Services Administration (HRSA) should identify exemplary models of coordinated systems of care for children and adolescents.
9.2 The Substance Abuse and Mental Health Services Administration (SAMHSA), National Institutes of Health (NIH) (National Institute on Alcoholism and Alcohol Abuse [NIAAA], National Institute on Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]), and the Health Resources and Services Administration (HRSA) should identify exemplary models of linking behavioral health treatment and prevention programs for children and adolescents to address suicide, substance abuse, and other areas.
9.3 The Substance Abuse and Mental Health Services Administration (SAMHSA), National Institutes of Health (NIH) (National Institute on Alcoholism and Alcohol Abuse [NIAAA], National Institute on Drug Abuse [NIDA], and National Institute of Mental Health [NIMH]), and the Health Resources and Services Administration (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 and private systems must make efforts to develop service capabilities to meet the needs of adolescents who are abusing alcohol or drugs and adolescents who have mental health problems.
10. CLINICAL PRACTICE GUIDELINES
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 guidelines 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 development of practice guidelines.
11. PRIMARY CARE
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 expanded 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 professionals” (IOM, 1996, p. 137).
11.2 This committee recommends that the above recommendation include alcohol and other drug abuse problems as a defined area of expertise.
12. ETHICAL CONCERNS
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:
a clear description of a plan, its benefits, and grievance procedures,
accessible and responsive grievance, complaint, and appeals procedures,
effective strategies to maintain confidentiality while meeting the needs of practitioners to coordinate care,
culturally appropriate and gender-specific service practitioners in the network,
consumer surveys and measures of consumer satisfaction,
consumer representation on policy development and grievance resolu
continuous improvement protocols to promote better outcomes, and
no contractual or other limitations for physicians and other practitioners concerning the discussion of clinically appropriate treatment options with patients and families.
12.2 A careful review of ethical issues in various settings, for example, managed care organizations, networks, and fee-for-service settings, is needed. The Substance Abuse and Mental Health Services Administration (SAMHSA), Health Care Financing Agency (HCFA), and Agency for Health Care Policy and Research (AHCPR) should develop a plan to examine ethical issues.
IOM (Institute of Medicine). 1996. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press.