Trends in Managed Care
Market forces are creating dramatic shifts in the structure and conduct of business in the health care delivery system. Employers, government agencies, and other purchasers of health care have become increasingly aggressive in demanding competitive prices from suppliers of health care services. The response to the new strategies in purchasing health care has been an acceleration in the growth of managed care organizations.
Managed care imposes organization, controls, quality measurement, and accountability on the delivery of health care to achieve the purchaser's goals for access to care, quality of care, effectiveness of care, and cost of care (Goldstein, 1989; Mechanic et al., 1995; Miller and Luft, 1994; Wells et al., 1995). The introduction and expansion of managed care strategies have altered the organization of general health care (e.g., Shortell et al., 1994) and have begun to influence the delivery of privately and publicly reimbursed mental health and substance abuse treatment. Because behavioral health care takes place in primary and specialty settings and because there is a distinct publicly paid and managed system for the delivery of behavioral health care, the introduction of managed care in one setting can change the relationship to health care in other settings.
Potential problems of the quality of and access to behavioral health care under the managed care system have long been concerns of policymakers. Demonstration projects in Medicaid within the private insurance industry provide some evidence of the impacts of managed care arrangements on utilization and quality (Mechanic et al., 1995). The evidence supports the ability of health maintenance organizations (HMOs) to control the costs of behavioral health care (Frank et al., 1995). There is also mounting evidence that specialty behavioral health compa-
nies and other approaches to managed care lower costs compared with the costs of indemnity insurance plans (e.g., Essock and Goldman, 1995; Frank et al., 1995).
This chapter discusses some of the major trends in managed care and their implications for behavioral health care: (1) the increasing rate of growth of managed care, (2) the rapid expansion in the use of managed care systems by public-sector populations, (3) the role of purchasers in managing costs, and (4) the recognition of quality assurance and quality improvement mechanisms as tools for purchasers in making informed decisions. The chapter provides an overview of different quality monitoring mechanisms, including accreditation, quality improvement, performance measurement, licensing, and other credentialing activities, and discusses consumer protections, including confidentiality. Although the responsibility for quality is diffuse, the committee believes that quality assurance and accreditation can be used as tools to help purchasers of care receive the most effective care at the lowest appropriate price.
THE CHANGING HEALTH CARE SYSTEM
Conventional insurance, also called indemnity or fee-for-service insurance, places few restrictions on the choice of practitioners whose services are covered. Practitioners are reimbursed on the basis of the numbers and types of services that they provide, which produces unintended consequences: an incentive for practitioners to provide more services and an incentive for patients to seek more services because they are paid for by a third party. Costs under indemnity coverage are typically controlled by higher copayments, strict limits on services, and lifetime limits on aggregate coverage.
In contrast, managed care imposes limitations on utilization by specifying which practitioners and which services are covered, and often also the number of allowable visits. Managed care comes in many forms and new structures continue to develop, making generalizations difficult. However, managed care plans have the following characteristics in common (HIAA, 1996):
they make arrangements with selected practitioners to furnish a specific set of health care services to enrollees;
they have explicit criteria and standards for the selection of practitioners;
they have formal programs for ongoing quality assurance, quality improvement, and utilization review; and
they have financial incentives for members to use the practitioners and procedures that are covered by the plan.
As discussed throughout this report, enrollment in managed care plans con-
tinues to increase in both the private and public sectors (see Table 1.2 and Table 1.4 in Chapter 1). Although many think of managed care as a recent phenomenon, it began in the 1930s with the first prepaid group practices, forerunners of what are now known as HMOs. Early practitioners of managed care believed that it was a way to improve quality and coordination of care, as well as to increase emphasis on prevention (Starr, 1982).
Since the mid-1980s, managed care has gone through three major phases (CSAT, 1994). The first phase focused on managing access to health care, primarily using utilization review and administrative barriers such as pre-admission certification. The second phase focused on managing benefits, and in addition to utilization review, added fee-for-service provider networks, selective contracting, and treatment planning. In the third phase, the focus is on managing care, with a shift from utilization review to utilization management and emphasis on appropriateness of care. The fourth phase, which has begun in the last few years, is outcomes management in an integrated services system with a full continuum of treatment services.
Many structures of managed care have evolved. As indicated in Table 2.1, the types of HMOs include staff model, group model, network model, independent practice association (IPA), and mixed model HMOs. HMOs rely on capitation (a prepaid, fixed amount, usually per enrolled member per month) and other incentives to control costs, including the use of nonphysician practitioners and lower-intensity treatments. The group practice structure of HMOs allows better coordination between primary care and specialty practitioners, because, for example, practitioners are co-located and medical records are more easily shared.
Another prominent type of managed care plan is the preferred provider organization (PPO), which offers more flexibility in choosing practitioners than HMOs but which still offers incentives for seeing selected practitioners. PPOs are networks of practitioners that are most often organized by insurers, managed care organizations, or groups of practitioners. The networks contract with groups of practitioners who agree to provide services for a negotiated fee schedule (HIAA, 1996). Individuals who want to see a practitioner who is outside of the network can do so, but there is a financial penalty.
Point-of-service plans (POS) combine features of HMOs and PPOs. They use a network of selected practitioners who are reimbursed by either capitation or fee-for-service. Individuals choose a primary care practitioner who controls access to specialists, and copayments for seeing practitioners within the plan are low. When individuals see practitioners outside the plan, they pay higher deductibles and copayments (HIAA, 1996).
Currently, the feature most associated with managed care is cost containment. Compared with indemnity plans, managed care plans have significantly lower rates of utilization of inpatient hospitalization, lower rates of utilization of more expensive and discretionary tests, increased utilization of preventive services, and mixed results on quality as measured through outcomes (Miller and
TABLE 2.1 Types of Managed Care Organizations
Type of Organization
Relevant Regulatory Bodies
Health Maintenance Organization (HMO)
Staff model (practitioners are salaried employees of the HMO)
Group model (HMO pays a group of practitioners a negotiated, per capita rate, which is then distributed among the individuals)
Network model (practitioners work out of their own offices under contract with the HMO)
Individual Practice Association (IPA) model (practitioners continue individual or group practice with compensation by capitation and/or fee-for-service [FFS] plans)
Mixed model (combination of two or more of the above)
An organized system of health care that provides a comprehensive range of health care services to a voluntarily enrolled population in a geographic area on a primarily prepaid and fixed periodic basis
National Committee for Quality Assurance (NCQA)
Accreditation Association for Ambulatory Health Care (AAAHC)
Utilization Review Accreditation Commission (URAC)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Federal licensing agencies, state insurance commissions, state departments of mental health, and state departments of public health
Preferred Provider Organization (PPO)
A network discount, FFS provider arrangement with incentives to stay inside the network; allows services outside of the PPO network at an increased copayment and/or deductible; has structured quality and utilization management
URAC (after its purchase of the American Accreditation Program, Inc.)
State insurance departments
An organized system of health care provided by an HMO model with the option of the delivery of services outside of the network at a higher copayment or deductible
State insurance departments
Management Services Organization (MSO)
An organization that provides practice management, administration, and support services to individual physicians or group practices
State insurance departments
Employee Assistance Programs (EAP)
Programs to assist employees, their family members, and employers in finding solutions for workplace and personal problems
The Employee Assistance Professional Association has a certification program (EAPA)
Managed Behavioral Health Care Organizations (MBHO)
An organized system of behavioral health care delivery usually to defined population or members of HMOs, PPOs, and other managed care structures; also known as a carve-out
Council on Accreditation of Services for Families and Children (COA)
Rehabilitation Accreditation Commission (CARF)
State insurance departments
State public health departments
State mental health departments
SOURCES: EAPA (1995), JCAHO (1996), NCQA (1995), and United HealthCareCorporation (1994).
Luft, 1994). Because of the demonstrations of cost savings, managed care has become more attractive to public agencies; for example, in 1995, 32 percent of Medicaid recipients were enrolled in managed care plans (HCFA, 1996).
Another feature of managed care is the development of specialty networks or “carve-outs” for mental health and substance abuse, cancer, vision, dental, and other types of care. Managed behavioral health care companies have been among the fastest growing in the managed care sector. Currently, 88 percent of the individuals in managed care and a total of 125 million individuals are enrolled in a variety of managed behavioral health care products ranging from utilization review only to capitated carve-outs. Carve-out vendors may be specialized units within larger managed care organizations or they may be independent companies.
Staff model HMOs have traditionally provided mental health and substance abuse care by their own staffs, now called a “carved-in” arrangement. In the area of mental health, HMOs have typically been found to spend only 3 to 5 percent of their budgets on mental health, whereas spending for mental health care is 10 percent of the overall budget for the health care system in general (Schadle and Christianson, 1988). These findings have led to concerns among consumers and family members about undertreatment, especially for individuals with serious and persistent mental illness (Flynn et al., 1994; Gerson, 1994). Another concern relates to adverse or biased selection, referring to the tendency for managed care organizations to enroll “good risks” or healthy individuals (Frank et al., 1995).
Increasingly, advocates look to managed behavioral health care to improve the quality of care for individuals with behavioral health problems, and because increasing numbers of public-sector clients are being enrolled in carve-outs, quality improvement is a high priority. The American Managed Behavioral Healthcare Organization (AMBHA) has developed its report card with input from consumer groups, such as the National Alliance for the Mentally Ill (NAMI). The Mental Health Statistics Improvement Program (MHSIP) involved consumer groups (e.g., NAMI and the National Empowerment Center) in developing a report card to evaluate mental health services. Although it is intended for all mental health services and is not specific to managed behavioral health care, the report card involved industry groups in its development. Field testing of the report card began in the summer of 1996.
Employers as Purchasers
As discussed in Chapter 1, employers are interested in the value of their investments in health care. They control the nature of competition among the health plans that are allowed to compete for a firm's employees and dependents. Control of competition occurs via the prequalification of plans, the initial negotiation of premiums, and the definitions of benefits and performance standards. Employees are then permitted to choose among qualified health plans. In many cases the premium subsidy is structured so that the employee must pay for pre-
mium costs above the cost of the lowest-priced plan. This competition for enrollees is thought to exert pressure to reduce premiums and to offer the opportunity to compete in the area of quality as well. In addition, the increased use of capitated payment methods for reimbursing health plans creates strong financial incentives for plans to reduce health care spending. Capitation refers to the practice of having fixed rates of payment for the provision of a specified group of services to a defined group of recipients. Usually, payment is made on a per-member, per-month basis.
Although it is not the dominant payment method, the use of capitation to create incentives for providers and practitioners has expanded. It is estimated that in 1994 about 20 percent of the population was served by a physician who was reimbursed under a capitation arrangement (Business and Health Magazine, 1995). This passes the strong financial incentives of capitation along to individual providers of care. Report cards and public reporting of responses to patient satisfaction surveys provide opportunities for employers and employees to choose among competing health plans by comparing the relative value offered by various plans.
The result of the combination of aggressive buying by employers and the use of competition has been a dramatic shift in enrollment patterns across plan types. Recent surveys by several large benefits consulting firms indicate that the portion of individuals covered by employer-sponsored insurance and enrolled in traditional indemnity plans (with or without precertification) fell from 53 percent in 1991 to 35 percent in 1994. In particular, PPOs, POS plans, and HMOs accounted for 63 percent of enrollees in employer sponsored health insurance plans in 1994 (Foster Higgins, Inc., 1994).
In addition, some employers report that they have been successful in obtaining premium reductions from health plans seeking to participate in their employee health programs. The overall result has been for average employee health care costs to rise only modestly among larger employers, whereas the increases in costs for other purchasers have been larger (IOM, 1993).
Financial incentives, provider selection, and utilization management techniques are used alone and in combination within most managed care plans (Freeman and Trabin, 1994; Goplerud, 1995; IOM, 1989). Financial incentives can be applied to consumers (deductibles and copayments) and providers (capitation or some other form of risk-based contracting) to discourage the use of costly services. Mandating the use of specific provider networks limits consumers' ability to choose practitioners, reduces the number of providers that can be reimbursed for care, facilitates the negotiation of contracts with favorable rates, and permits more scrutiny of the quality of care than reimbursing individual practitioners on a fee-for-service basis. Finally, utilization management applies treatment guidelines, protocols, and professional judgment through prior review (are services appropriate and necessary?) and high-cost case management (a review of high-expenditure cases to facilitate less costly care) to reduce the expense of care and enhance the consistency and quality of care (IOM, 1989).
State Governments as Purchasers
States and counties have the responsibility for managing public systems of care, and their objectives with regard to health plans and services differ somewhat from the objectives of private employers. For example, a state may place priority on offering a minimum level of access to basic medical care to achieve the lowest “on-budget” cost. The configurations and structural relationships among the Medicaid agency, state mental health and substance abuse authorities, and child welfare systems are different in each state, as are the economic and political environments, so the routes to cost-effective care differ in each state (Essock and Goldman, 1995).
By August of 1996, 29 states had received federal waivers to restructure their Medicaid programs, often in response to state legislative mandates to expand coverage for poor people who would otherwise not qualify for Medicaid (GAO, 1995). Expansion of the numbers of people enrolled in the Medicaid program requires the realization of savings from care for currently covered enrollees to finance the expansion of coverage to new populations. One way to achieve the savings is through capitated health plans.
As of June 1995, about 32 percent of Medicaid program beneficiaries were enrolled in capitated managed health care plans (HCFA, 1996). This segment of the Medicaid market is growing rapidly. States are active buyers of managed care services for their Medicaid enrollees and make use of competition to enter the program to obtain favorable premiums. Because Medicaid enrollees do not pay premiums, competition for enrollees is used primarily as a quality control mechanism. That is, if a plan offers insufficient quality, enrollees may choose some alternative plan that might offer more satisfactory services.
CONCERNS WITH MANAGED CARE IN THE PUBLIC SECTOR
The introduction of managed care into already existing public-sector service systems represents a reorganization of service delivery and creates opportunities to address many limitations of the current systems of care for individuals with mental health and substance abuse problems. Purchasers with vision can use managed care arrangements to achieve specific goals: improve access to care, enhance the quality of care, better manage the cost of care, increase the effectiveness of care, and facilitate prevention initiatives. Indeed, increased use of managed care tools can be a key strategy to facilitate improved integration of the separate and distinct public and private systems of care that are a problematic aspect of mental health and substance abuse care.
However, debate on the use of managed care for behavioral health care (mental health and substance abuse treatment) can be intense because there is evidence that individuals with chronic conditions including mental illness and substance abuse may have more difficulty receiving adequate and effective services
when they are enrolled in managed care plans (Christianson et al., 1989; Mechanic and Aiken, 1989). One study comparing psychiatric treatment within prepaid managed care plans and fee-for-service arrangements found that half of the individuals receiving care through a managed care plan developed new functional limitations over time, whereas those receiving care through a fee-for-service plan did not (Rogers et al., 1993).
Some believe that the techniques used by managed care plans can facilitate access to care and improve the quality of services because provider flexibility can be enhanced and care can be individualized; others are concerned that managed care models can inhibit access and interfere with appropriate and individualized care (e.g., Boyle and Callahan, 1995; Gold et al., 1995; Kassirer, 1995; Sabin, 1995; Schlesinger, 1995; Schlesinger and Mechanic, 1993; Surles, 1995). Moreover, the prepaid capitated financing characteristic of managed care plans is frequently distrusted because of the potential financial incentives to minimize care and maximize profits (e.g., Boyle and Callahan, 1995; Iglehart, 1996; Sharfstein and Stoline, 1992)
Effective managed care programs manage expenditures. Purchasers can increase or decrease the amount of financial risk that a managed care organization assumes and can potentially reduce the incentives to limit access and utilization of expensive technologies, specialty services, and long-term care (Frank et al., 1995). One important component in managing costs is the analysis of the incentives and disincentives included in the contracts between the purchaser and the managed care organization and between the managed care organization and the provider. Frank and colleagues (1995) have examined public and private contracts for managed behavioral health care, and they suggest that purchasers may achieve a balance between cost control and access through the use of “soft” capitation, which shares risks between the purchaser and managed care organization, thereby reducing the potential profit and losses for the managed care organization. Soft capitation can promote reinvestment of “savings” into increased benefits or expanded eligibility by giving governments a share of the “profits. ”
Public providers of community-based services who are eager to share in the potential profits related to the use of capitation have negotiated subcapitation rates. They agree to provide necessary services to a specified population for a portion of the total capitation—a subcapitation. Subcapitated providers can profit from treating patients. Each subsequent layer of subcontracting draws an administrative fee, which reduces the funds ultimately available for direct services. Inexperience with managing populations of enrollees may also lead to setting rates that are too low, thereby threatening access and quality of care.
Direct and insufficiently planned applications of private-sector managed care models to public-sector systems that serve men and women with serious mental illness and chronic substance abuse are unlikely to be successful. Many employer-purchased managed care plans explicitly exclude social and support services, and because they emphasize acute care, they tend to have little experience in the management of chronic and disabling conditions.
Changes in service systems may also threaten the continued viability of the agencies and providers that have served the more complex and vulnerable uninsured and publicly insured consumers with distinction. At the same time, many of the tools of private-sector managed care have relevance to public-sector systems. For example, integrated management information systems, decision-making algorithms, and methods of developing and improving provider networks have great applicability to public-sector systems. The ability of public systems to implement these strategies, however, may be limited by budgetary constraints, procurement policies, personnel capacity, and other factors.
Integration of service delivery across a broad range of services is a challenge to achieving effective and efficient services. Carve-in or integrated policies, most common in staff model HMOs, can increase the likelihood of coordination and communication among primary care and specialty providers. Carve-out vendors have the advantages of having better linkages with employee assistance programs, more specialized quality measurement tools, more specialized practitioners, and the ability to provide consistent benefits anywhere in the country (IOM, 1996).
Integration of services requires resource management that coordinates benefits from multiple entitlements and services from diverse and multiple providers. Case management to support transitions (transition management) can help individuals moving across settings and to care outside the system. Regular screening of populations and internal referral systems among key providers are needed to support aggressive case finding and early intervention. Multidimensional assessments need to include the medical, personal care, mental health, substance abuse, and social facets of need, but comprehensive approaches are very difficult to coordinate. One way to assist in coordination is to include in contracts requirements for linkages to support wraparound services such as transportation and child care (Institute for Health Policy, 1995).
BEHAVIORAL HEALTH IN THE NEW MARKETPLACE
As employers and states have moved in the direction of contracting with managed care organizations to care for at-risk individuals, providers, consumers, and policymakers have become concerned about the consequences of these developments with regard to access to care and the quality of treatment for individuals suffering from mental health and substance abuse problems. Individuals
suffering from severe forms of mental and addictive disorders have been identified as being at risk for neglect under these new market arrangements (Boyle and Callahan, 1995). The question that stems from such concerns is, how can behavioral health care productively fit into the larger health care system?
This section focuses on one dimension of making markets more accommodating to behavioral health care. That dimension involves improving the information available on the quality of health plans in providing behavioral health care services. Information on quality is one aspect of the choices available to purchasers and policymakers in the behavioral health care arena. It is, however, an important choice and arises as an issue under all types of organizational and financial arrangements, albeit in different forms.
In many respects, the behavioral health care market is being transformed from transactions based on services to transactions based on people. Behavioral health care organizations are increasingly competing for the right to serve populations. In some cases, this competition comes in the forms described above, in which individuals choose from among competing health plans. In other cases, a purchaser (employers or a government) will carve out behavioral health care and will competitively select a single managed care vendor (Frank et al., 1995). Risk-sharing arrangements are increasingly common for both health plans and carve-out programs. These can involve establishing financial arrangements, utilization controls, and other mechanisms to share the financial risk of providing care among health plans or other providers, payers, and users of a health care plan. In a risk-sharing arrangement, health plans face at least some financial risk for the costs incurred on behalf of their enrollees.
Initial results from the transformation of behavioral health care markets are dramatic. Managed behavioral health care has shown that in many cases it can result in significant reductions in behavioral health care spending (Mechanic et al., 1995). Treatment patterns are changing, often in directions that have long been viewed as desirable. For example, in the mental health area, adoption of a managed behavioral health care program is often accompanied by a reduced reliance on hospital-based inpatient care and a greater emphasis on community-based alternatives (Callahan et al., 1994). In the substance abuse area, managed behavioral health care plans result in dramatic reductions in the use of 28-day inpatient programs and the expanded use of residential treatment programs.
Many of the criticisms of the new organizational and financial arrangements associated with managed behavioral health care stem from their efforts to respond to certain problems inherent in trying to insure health care. One of these problems involves the utilization effect of health insurance; the other is the problem of biased risk selection.
The utilization effect of health insurance (sometimes called moral hazard) refers to the tendency of those who are insured to use more health services—both appropriate and inappropriate—than those people would use if they were responsible for the full cost of care. Ideally, health plans could respond with strategies
that selectively reduced inappropriate use of services. That this has proved very difficult in most areas of health care is indicated by research showing that most cost containment tools affect most needed and unneeded services. Behavioral health care may face particular challenges in calibrating strategies to minimize harm because measures of need, outcomes, appropriateness, and effectiveness—although improving —still lag behind efforts in other areas of health care.
Given the pressures on health plans to reduce costs, consumers who need behavioral health care may thus be especially vulnerable to cost control strategies that unselectively affect the quality and accessibility of appropriate services. Another problem for those who use behavioral health care in a competitive market is the challenge of functioning well in the consumer role. Particularly for individuals who are in crisis, it may be particularly difficult to negotiate the administrative requirements for obtaining care, or to challenge adverse administrative decisions.
Adverse (biased) selection creates market failure in several ways. Individuals typically know more than their health plans about their own health status. Hence, consumers will naturally choose plans that offer provisions that are best aligned with their anticipated health care needs. It is therefore possible that individuals with behavioral health problems and family members who act on their behalf will be more likely to foresee their use of health care services than other individuals. For this reason health plans that offer generous coverage and high-quality behavioral health care services or that allow relatively free access to services will disproportionately attract users of behavioral health services to their plans. Because mental and addictive disorders can be chronic and relapsing problems, people who experience these problems can incur additional medical expenses and thus can accumulate high overall costs for their care.
Under such circumstances, premiums based on population averages may be too low. Thus, there are strong incentives to compete for individuals who are “good risks” (McGuire, 1989). The implications will be that plans will compete to avoid attracting enrollees who are likely to use behavioral health care services. These competitive dynamics lead plans to limit coverage, access, and quality in the behavioral health care arena.
Another aspect of adverse selection occurs because purchasers of all types (individuals, employers, and governments) cannot obtain information on quality but do have access to information on price (Akerlof, 1970). When only this one aspect of information is measurable, purchasers may place excessive weight on price in the absence of reliable information on quality.
At the public workshops convened by the committee, a variety of parties from the managed behavioral health care industry and from the purchaser community suggested that price was most important to government and corporate purchasers. This is true both in the context of behavioral health carve-out purchases and for purchasers choosing plans that will be permitted to compete for a population of enrollees. The result is that plans will be rewarded by the market for achieving lower prices by reducing quality. Higher-quality, higher-cost providers
will be disadvantaged in competition and possibly driven from the market. Again, because quality in the behavioral health care arena is more difficult to measure than in the general medical care behavioral health arena, services are particularly vulnerable to such quality reductions.
Whether we like it or not, behaviors are very financially driven. When I was in the managed care industry as director of provider networks, we moved a group from a fee-for-service group to a capitated group, and in the first month of the capitation, their inpatient rate dropped 50 percent. Now, the question is, did it drop from 100 percent too much to exactly the right amount, could it have dropped further, did it drop too much? I don't know that we were clear on that.
William R. Mercer
Public Workshop, May 17, 1996, Irvine, CA
The relative importance of biased risk selection and moral hazard will depend in part on the specific organizational and financial arrangements involved in choosing health care plans. For example, if a single behavioral health care vendor is chosen, the problems related to incentives created by risk selection are largely eliminated because the vendor would be the only source of care for a defined population. In contrast, if a purchaser allows individuals to select among competing health plans (either integrated or carved out), the plans' enrollees could present different levels of risk to the plans in terms of the likelihood of needing care. When a health plan attracts a more risky or more costly group than the average, or than the competition, it has experienced adverse selection (IOM, 1993).
In Medicaid programs and private insurance plans, choices about how to organize the purchase of behavioral health services are quite similar. In comparison, public mental health and substance abuse systems typically face more complexity with respect to moral hazard because these systems serve as the provider of last resort in the United States. Thus, these systems must serve all those who need treatment and who are unable to pay for care. However, there is no “denominator population” for which to construct a capitation rate (fixed rate of payment per enrollee per month) and thus no way to accurately estimate the possible costs of care. Thus, a managed care vendor serving the public system potentially may face more financial risk.
With the incentives to produce cost savings comes a risk of cost shifting, or a redistribution of payment sources, For example, when one payer obtains a discount on services from a particular provider group, the provider group might increase their costs to another payer to make up the difference. In the context of managed behavioral health care, the concern is that the costs of care for seriously mentally ill individuals might be shifted by private companies to the public sector.
Another way in which cost savings might be achieved is sometimes called “skimming,” which refers to the practice of only enrolling the healthiest individuals in an insured population. Policies that might support this practice could include having very few behavioral health providers and practitioners in a network, or having them located in areas that are difficult to reach through public transportation. Another policy might be to define behavioral health problems, especially severe problems, as being outside of the responsibility of the health plan. Some of the ways to avoid these practices are discussed in a later section of this chapter on contracting and contract language.
HEALTH CARE QUALITY
Moving away from an exclusive interest in cost, purchasers are beginning to demand documentation that services are effective. Thus, the introduction of managed care can stimulate the development of treatment guidelines and standards of care, improve the delivery and monitoring of care, and encourage linkages between research and practice. Because plans are developed for the benefit of specific groups of eligible consumers, consumer report cards and measures of satisfaction can become important indicators of effectiveness.
Managed care and managed behavioral health care organizations are now competing on the basis of both quality of care and cost of care (England and Vaccaro, 1991 ). Digital Equipment Corporation's (1995) HMO Performance Standards reflect one purchaser's requirement for specific levels of quality in the health plans that it purchases for its employees and beneficiaries. Quality standards for behavioral health care are being promulgated and implemented by accreditation agencies (NCQA, 1996) and promoted by trade organizations (AMBHA, 1995).
Well-developed quality improvement initiatives use management information systems to monitor and manage clinical processes to enhance client outcomes. AMBHA's (1995) quality standards emphasize continuity of care, follow-up, and readmission rates. Digital Equipment Corporation 's (1995) standards for behavioral health care require quality improvement plans, requirements for staffing levels and staff credentials, and access to case management to support the treatment interventions. These and other standards will be discussed further in Chapter 6, Process.
On a quarterly basis we feed back to all our providers how they've done compared to the rest of the plan in terms of their utilization statistics, their quality improvement statistics, their outcomes, the complaints and grievances, and their administrative compliance to the plan.
Vista Behavioral Health
Public Workshop, May 17, 1996, Irvine, CA
Context for Accreditation and Outcome Measurement
Although accreditation approaches and measurement of outcomes are central issues in ensuring the quality of managed behavioral health care systems, a range of other factors and approaches critically shape, affect, and address the quality of care. The unique structure of behavioral health care itself creates fundamental quality issues. Since most commercial insurance coverage is limited, commercially paid care is fragmented between primary and specialty sectors and there is a substantial public sector that serves as a safety net. Cost shifting and other relationships between sectors of care are in themselves a crucial problem. Furthermore, the complex framework for quality is itself a challenge for ensuring and improving quality.
As Table 2.2 illustrates, responsibility for quality is divided, and fundamental issues of coverage, benefit adequacy, and system design exert a profound effect on quality. For example, the typically limited behavioral health care benefits in most commercial insurance plans—especially in an environment of cost control—lead to a shift of consumers with high levels of need to the public sector. In the public sector, state-to-state variability in funding patterns, organization, and service adequacy lead to idiosyncratic patterns of care.
The array of approaches to monitoring service processes and outcomes is also complex. Responsibility for addressing quality is diffuse. Providers use their own measures and approaches to improve the quality of the care that they provide (e.g., quality assurance and continuous quality improvement). Thus, the responsibility for quality starts at the level of the providers.
Accrediting organizations (historically, especially JCAHO) have required providers to develop and implement internal quality assurance systems. Pressure to develop internal quality improvement activities may paradoxically be a positive result of external accreditation approaches.
States regulate health care practice by licensing individual practitioners, for example, physicians, nurses, psychologists, and social workers (see Table 4.1). Different states have different approaches to licensure, for example, whether so-
TABLE 2.2 Ecology of Consumer Protection: Current Context
Context/Environment of Coverage
Workplace to employee assistance program (EAP)
EAP to Health Care
Benefits And Services
Narrow, shallow benefits
Deep, broad benefits
Accreditation of Plans
Tend to focus on commercial market
Early in development
Weak on disabled population and care other than medical care
Quality Improvement In Plans
State Certification Standards
Standards for systems of care; certification or contract/plan specifications
Standards for providers, not plans
May duplicate accreditation
Cover care other than medical care
State Professional Licensure Standards
Internal, e.g., surveys
External, e.g., Ohio Consumer Quality Review Team
Highly relevant to consumers in public sector
Covers wide range of issues, including quality of life and care other than medical care
Being field tested
Pilot testing under way
Focuses on feasibility of collecting outcome data from individuals with depression and schizophrenia
System Performance Standards
Sums process measures
Wide database Focuses on medical/clinical issues
aPERMS, Performance-Based Measures For Managed Behavioral Healthcare Programs.
cial workers are licensed or whether nurses have prescription-writing privileges. However, the licensure standards within each profession are generally comparable from state to state. Licensure approaches require evidence of adequate training and credentials and of continuing education, and state licensure boards monitor problems of egregiously poor care, although instances of inadequate or inappropriate care are probably underreported.
States also license or certify provider agencies, for example, mental health centers, against minimum standards of staffing, facilities, and organization. This
certification may be carried out by the funding agency or the state health department and is typically required if an agency is to receive state funding or to participate in the Medicaid program. State certification standards are somewhat variable in both coverage and intensity; they are a corporate analog of the licensure of individual professionals. State certification of agencies is usually not required for participation of the agency in commercially paid insurance plans. States also regulate insurance plans, such as HMOs, although the regulation of specialty managed care entities is in its infancy.
In theory, the prepaid capitated health care system increases incentives for a plan to prevent health care problems and to identify emerging problems early. Investments in some prevention activities and early interventions may reduce the cost of treatment. Prevention services, however, often require years before their effects can be discerned, and managed care organizations may have relatively little incentive to prevent conditions they may never be required to treat because of enrollee mobility.
Among the most readily available quality standards for behavioral health care, only Digital Equipment Corporation's (1995) HMO Performance Standards address prevention and early intervention. Digital requires health promotion activities and health education and supports a strong employees assistance program (EAP), and thus does not require screening and early intervention for substance abuse and mental health problems (Digital Equipment Corporation, 1995).
In planning for this capitation, the managed care organizations were really convinced that they wanted to, they had the responsibility to, and to a great degree were motivated to keep these patients well and out of the hospital.
Oregon Health Department
Public Workshop, May 17, 1996, Irvine, CA
In public managed care programs there may be increased value for the inclusion of screening and the early identification of problems in the design of the benefits package. The Oregon plan for Medicaid recipients, for example, requires HMOs to screen Medicaid beneficiaries for the presence of substance abuse problems and to refer them for assessment and treatment if necessary. Similarly, some
jurisdictions, such as Indian Health Service hospitals, require screenings for alcohol among trauma patients seen in emergency rooms.
Licensure and Certification
Before the federal government's adoption of the Hughes Act [the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91-616)] and, at the state level, the decriminalization of public intoxication and the authorization of alternatives to incarceration for treatment, formal treatment for alcoholism was primarily provided in state mental hospitals and a small number of outpatient clinics and halfway houses (IOM, 1990a; NIAAA, 1971). Systems of care did not exist in most states. Both the Hughes Act and the Uniform Alcoholism and Intoxication Treatment Act (P.L. 94-371) included provisions for a state alcoholism authority that would plan, coordinate, fund, and regulate alcoholism treatment and prevention services in the state. Section 9 of the Uniform Act empowers the states with the authority to set standards for treatment facilities and to approve public and private facilities to deliver care (NIAAA, 1971).
Although the specific powers vary from state to state, third-party payers typically require state licensure or approval before they will provide reimbursement for care in a facility. State licensure or approval therefore became a key tool in the development of systems of care. Licensure and approval thus are required to legitimize programs, ensure quality, and protect consumers (Birch and Davis Associates, Inc., 1984; IOM, 1990b).
State regulations for treatment facilities usually establish requirements for space, staff, services, and record keeping. A review of state licensing practices completed in 1992 found that although all states specify requirements for treatment providers, compliance in some states is voluntary (Health Management Resources, Inc., and Birch and Davis Associates, Inc., 1992).
The introduction of managed care has challenged state licensing systems because some new models of care may not fit existing licensing categories (e.g., home detoxification services). Although the managed care plans may urge minimal state regulation to minimize their costs and maximize creative treatment planning, consumers may be less protected because standards of care have not been established for many emerging treatment techniques.
Thus, licensure has been developed for individual practitioners and facilities. The ability of licensure to control quality, however, is unclear. For example, licensure for mental health professionals emphasizes educational degrees, performance on written tests, familiarity with the statutes and regulations applicable in a given state, and specific courses of study. Actual effectiveness or skill during treatment is not tested directly, because it is assumed to have been attained during the accumulation of a required number of hours of supervised experience. Performance-based credentialing of the workforce, which bases certification on
direct evidence of skills, has developed in some parts of the mental health workplace (e.g., biofeedback). In general, however, licensure as a consumer protection strategy has not been evaluated.
The workforce in behavioral health care is unusual in that it includes many counselors who have experience but not necessarily professional training. Counselor certification has been encouraged to legitimize the field of addictions counseling, demonstrate that individual counselors are qualified to provide counseling services, and promote the development of a professional identity (Birch and Davis Associates, Inc., 1984; Valle, 1979). Certification specifies counselor qualifications rather than educational degrees (Birch and Davis Associates, Inc., 1984; Valle, 1979).
Because the field of substance abuse counseling includes many men and women whose initial involvement with training is their personal experience of recovery, the need to demonstrate competence and skill has been especially acute. The development of credentialing standards was an early priority for the field and, with support from the National Institute on Alcohol Abuse and Alcoholism, trade groups collaborated and proposed 12 core competency areas and credentialing guidelines (Birch and Davis Associates, Inc., 1984). A review of state procedures for the certification of substance abuse counselors found that all states support certification, but in most states the certification is voluntary and coordinated through an independent nongovernmental entity, usually a trade group organization (Health Management Resources, Inc., and Birch and Davis Associates, Inc., 1992).
Debate about the role of individuals who are in recovery as counselors (experiential counselors) has persisted over the decades. Krystal and Moore (1963) debated the issue in the early 1960s; Krystal argued that alcoholism is a complex disease that requires professionally trained counselors, whereas Moore believed that psychotherapy is unnecessary in most cases and that physicians and psychologists should work closely with counselors who are themselves in recovery. In practice, experiential counselors became a major part of the workforce in the emerging alcoholism and drug abuse treatment programs. Counselors in recovery are more likely to be older and male and to work in residential treatment settings (McGovern and Armstrong, 1987; Mulligan et al., 1989).
Research on treatment effectiveness tends not to evaluate differences among types of practitioners. Within the managed care environment which emphasizes ambulatory care and lower-cost practitioners, it would seem to be desirable to employ counselors rather than psychiatrists or other mental health professionals. However, the role and status of experiential counselors appears to be limited. Although counselors with certification are more competitive, it appears that many managed care plans also require an individual to have graduate training and a
master's degree to serve their members. The National Association of Alcoholism and Drug Abuse Counselors (a professional organization for certified addiction counselors) therefore advocates certification requirements for degreed and nondegreed counselors as evidence that counselors are not only professionally trained but are also skilled in the treatment of addictions (NAADAC, 1988, 1991, 1994).
Academic preparation does not make you a better clinician, to be honest. It may give you a better grounding in theory. It does not make you a better clinician.
National Association of Alcohol and Drug Abuse Counselors
Public Workshop, April 18, 1996, Washington, DC
Loss of Current Providers
Public-sector service systems often appear to be a patchwork of service agencies that specialize in the unique and complex needs found among uninsured individuals and individuals with public insurance. The service providers may include state and county hospitals and clinics, as well as private nonprofit agencies such as community-based programs staffed with licensed, certified, and noncertified counselors. In contrast to the private sector, where individual practitioners must meet licensing and other standards, the public sector has a long tradition of accreditation at the program level. When managed care networks expand, they tend to recruit individual practitioners rather than programs. Consequently, networks may exclude the practitioners with the greatest understanding and experience working with publicly financed consumers of health care.
One strategy to limit the disruption of care is to require managed care organizations to include public-sector providers, such as halfway houses or therapeutic communities, in their service networks. Because they have operated under different types of accreditation, however, some publicly funded providers may have difficulty meeting the performance expectations and abiding with service and cost restrictions. For example, halfway houses are an important social support service when inpatient care is not available or not appropriate. Support for system development may be required for many providers to facilitate their change to a managed care environment.
Clinical Practice Guidelines
In an earlier report, the Institute of Medicine (IOM) (1990c) defined clinical practice guidelines as systematically developed statements that could be used to assist practitioner and patient decision-making about appropriate health care for specific clinical circumstances. They are intended to improve the quality, appropriateness, and effectiveness of care, and they have been used to help guide clinical decision-making, to assist organizations in developing their own clinical and risk management protocols, to guide payers in setting reimbursement policies, and to assist consumers in making informed choices regarding their health care (Edmunds, 1996).
Clinical practice guidelines are seen by federal policymakers as a key activity in rationalizing decision-making about the delivery of health care and in reducing variation for nonclinical reasons such as local patterns of practice (Edmunds, 1996). In its 1989 report to the U.S. Congress, the Physician Payment Review Commission recommended increases in funding for the development, implementation, and evaluation of practice guidelines and for outcomes research on which to base those guidelines (PPRC, 1989). In that same year, Congress passed legislation creating as a part of the U.S. Public Health Service the Agency for Health Care Policy and Research (AHCPR) to carry out those responsibilities (Gray, 1992).
National professional associations, such as the American Medical Association (AMA), the American Psychiatric Association, and federal agencies, particularly AHCPR, develop practice guidelines recommending treatment approaches for particular conditions such as depression in the primary care setting (DHHS, 1993). These guidelines are generally developed on the basis of a review of the literature regarding treatment effectiveness and use a professional consensus development process.
Approximately 1,600 guidelines from 45 national medical groups and several other organizations are listed in the directory of guidelines published by the AMA (1993). Hundreds of proprietary guidelines have been developed in the managed care sector. Consequently, it is not unusual to find conflicting recommendations, various degrees of involvement by clinicians in their development, and various amounts of research cited as evidence. Some guidelines are intended to reduce costs by eliminating unnecessary and ineffective procedures and improving the coordination of care, but others can increase costs by recommending additional services and procedures.
Guidelines developed by a consulting firm, Milliman and Robertson, Inc., are used by health plans at Prudential, Cigna, U.S. Healthcare, Kaiser Permanente, and many Blue Cross and Blue Shield affiliates, affecting a combined total of 50 million members, subscribers, or covered lives. The Harvard Pilgrim Health Plan has undertaken an evaluation of the impact of the guidelines
of Milliman and Robertson, Inc., on cost and quality of care, with implications for future practice (Myerson, 1995).
Guidelines have the potential to allow for the coordination of the delivery of care, improve the quality of care, and standardize the collection of clinical data for use in outcomes research. The development of guidelines can help to bring about consensus and agreement among a variety of practitioners and purchasers about best practices. The use of practice guidelines by providers is increasingly required by accreditation bodies. However, much remains to be learned about the effective implementation of guidelines to produce changes in provider behavior and influence practice patterns.
QUALITY IMPROVEMENT AND QUALITY ASSURANCE
Donabedian's (1980, 1982, 1985) pioneering efforts to define and measure the quality of health care recognized that consumer sentiments and desires were essential components of quality measurement and that analysis of cost could not be divorced from the assessment of quality. In many ways, his discussions anticipated contemporary debate about the need to balance quality and cost within managed care environments. Donabedian's categorization of variables into “structure” (staff and facility resources and standard procedures), “process” (the delivery of care), and “outcome” (the results of care) continues to provide a useful conceptual framework for analysis of the variables that can affect the quality of medical products and health care services.
Concepts of total quality management and continuous improvement evolved from efforts of Japanese manufacturers to improve products, increase productivity, and reduce costs (e.g., Deming, 1986; Imai, 1986; Juran, 1988). During the 1980s, however, improvements in the quality of care occurred slowly, in part because the tools used to measure health care quality and monitor health care processes had not been developed and it was unclear how health care practitioners and systems could adapt the quality improvement tools developed for industrial environments (Berwick et al., 1991).
Quality improvement represents an evolution and enhancement of the technology developed for quality control and assurance. Quality was originally managed through inspection—finished products were examined to detect flaws, and if they were not satisfactory, they were returned for additional work or discarded. The approach was therefore inherently reactive: errors were corrected after they occurred. Short-term goals were emphasized and production quotas were used to monitor productivity. There was also an adversarial element, in that an inspector or supervisor would review the product and judge the quality of the product and, implicitly, the quality of the worker responsible for the product. Systems based on this model (results-oriented management) do not encourage innovation, do not empower workers to assume greater responsibility, and encourage games that inhibit the identification and correction of problems (Imai, 1986; Scholtes, 1988).
Quality improvement strategies, on the other hand, attempt to prevent problems from occurring so that corrective efforts are not required. Management and supervision become proactive and emphasize processes (process-oriented management); individuals are not blamed, processes are reviewed and critiqued, barriers that inhibit quality are eliminated, workers are encouraged and empowered to participate and assume responsibility, and products are designed to meet the needs and desires of both internal and external customers (Imai, 1986; Scholtes, 1988).
An IOM committee that examined quality review and assurance for Medicare (1990b) compared quality assurance and quality improvement models. They found that although both emphasize outcomes and stress the linkages between processes, the models differed on five dimensions (IOM, 1990b):
First, quality improvement models require continuous efforts at improvement even when high levels of quality have been achieved; quality assurance efforts, in contrast, would be directed at other issues once specific problems were resolved.
Second, a consumer perspective is essential to quality improvement efforts and identifies communication and interorganizational relationships that may be overlooked in quality assurance reviews.
The third difference between the two approaches is a quality improvement interest in patient needs, experiences, and satisfaction that is usually not part of quality assurance.
Fourth, quality improvement efforts attempt to improve mean performance levels, whereas quality assurance reviews focus on the identification and removal of outliers.
The last difference is the role of leadership; quality improvement programs require the organizational leadership to assume overall responsibility for persistent improvements in quality and to empower individual workers to participate in and contribute to the transformation of the organization.
The IOM (1990b) review also cautioned that there were few demonstrations of the application of quality improvement techniques to clinical care issues, and the usefulness of these tools to health care was unknown. Nonetheless, by 1992 an IOM committee that examined clinical guidelines found growing interest in quality improvement models within health care settings (IOM, 1992). The National Demonstration Project was an early effort to begin a transformation of health care and increase the use of quality improvement techniques (see Box 2.1).
The key to quality improvement is a change in perspective. Instead of assessing quality through inspection of people and products, processes and systems are created and monitored to prevent flaws and problems, and because quality is determined by the customer, products and services are designed to meet consumer needs and expectations (Berwick et al., 1991; Imai, 1986). Quality improvement also requires the application of scientific methods to the analysis and monitoring
BOX 2.1 National Demonstration Project on Quality Improvement in Health Care: Applications and Implementation
In 1987 and 1988, the National Demonstration Project on Quality Improvement in Health Care worked with 21 U.S. health care organizations and examined the application of the quality management technology developed for manufacturing processes to the delivery of health care. Ten management principles guided efforts in the National Demonstration Project (Berwick et al., 1991):
of processes, that is, statistical thinking. Decisions are based on data rather than intuition, so information systems are built and graphical tools are used to monitor critical processes and track the effects of alterations in the delivery of a service or the production of a product
Using these tools, workers are empowered to continually adjust the process and make consistent and persistent improvements in both process and outcomes. Gradual improvement in all aspects of life, but particularly the quality of the environment, process, and products of work, is embodied in the Japanese word kaizen (ky'zen) (Imai, 1986). A commitment to kaizen requires a careful understanding of processes, systems, and consumers and the application of strategies and tools to the production and delivery of high-quality products and services. The focus on long-term gradual improvement by using scientific methods and by paying attention to consumer needs characterizes true quality improvement orientations.
Quality Improvement in Health Care
Application of quality improvement methods has expanded substantially in health care settings. An annual review of the U.S. health care system reported that 94 percent of hospital chief executives believed that quality improvement programs would enhance efficiencies and reduce costs; 61 percent anticipated increased market share because of quality improvement initiatives (Business and Health Magazine, 1993). Increasingly, accreditation agencies and purchasers expect organizations to have formal quality improvement programs and assess the quality improvement processes as part of their review of a health care organizations (e.g., AMBHA, 1995; CARF, 1996; Digital Equipment Corporation, 1995; NCQA, 1996; URAC, 1996). Similarly, the federal Health Care Financing Administration is responsible for monitoring the quality of services for Medicare recipients and is supporting a quality improvement initiative that emphasizes continuous quality improvement methods, makes information available to the public, is consistent with state and private certification and accreditation programs, and employs multiple measures of quality and performance (GAO, 1996).
Improvements in patient care and outcomes are the ultimate result of quality improvement technology within health care settings. Applications are inhibited, however, because of the variable presentation of illnesses, variations in practice patterns, the hierarchical structure of patient care, and the complexity of hospitals and managed care programs. The “gold standard” for effectiveness continues to be randomized clinical trials, which are prohibitively expensive.
It is therefore noteworthy, for example, that the Northern New England Cardiovascular Disease Study Group applied quality improvement techniques and documented a significant reduction in hospital mortality associated with coronary artery bypass graft surgery in a multi-institutional regional environment (O'Connor et al., 1996). Clinicians, administrators, and researchers from the five hospitals in Vermont, New Hampshire, and Maine where coronary artery bypass
graft surgery is performed created a patient registry in 1987 and began a quality improvement initiative in 1990. The initiative involved three kinds of intervention: feedback of outcome data to practitioners, training in continuous quality improvement techniques, and site visits to other medical centers.
Data from 1993 suggested a cumulative reduction of 74 deaths from the mortality levels expected before the quality improvement intervention —a 24 percent reduction. The five institutions made multiple changes in procedures and techniques, so there was no single cause for the decline in mortality; rather, the observed improvements were due to the net effect of their efforts to learn and improve (Berwick, 1996).
Berwick (1996), in commenting on the study group's report, suggests that this type of discovery may be more valuable than randomized clinical trials for cumulative improvement and for the identification of techniques that enhance health care and reduce costs. It is also critical, he argues, that such information be reported to and published in peer-reviewed journals and not be guarded as proprietary information. The techniques and outcomes will be most useful if they are incorporated into clinical guidelines and protocols
Quality Improvement in Behavioral Health Care
Comparable demonstrations of the successful application of quality improvement methods to improved patient outcomes do not appear to exist for mental health and substance abuse treatment services. Both public- and private-sector treatment systems, however, have begun to adapt and apply quality improvement technologies.
In Massachusetts, for example, the Quality Improvement Collaborative is a peer-reviewed total quality management initiative designed to foster the introduction and use of continuous improvement protocols within all of the substance abuse treatment programs under contract with the Massachusetts Department of Public Health's Bureau of Substance Abuse Services (Fishbein and McCarty, in press). Detoxification centers adopted and implemented a model clinical record, and methadone services standardized evaluations of their clients' progress and linked a client's progress to the phases of care; evidence of improvements in patient care, however, are not yet available.
The Massachusetts Medicaid program has also applied quality improvement methods to the management of relationships with its suppliers (managed care organizations and health care providers) and reports improved responsiveness among the suppliers of health care (Friedman et al., 1995). As a result of this initiative, the managed behavioral health care organization responsible for the management of mental health and substance abuse services for the Massachusetts Medicaid program developed its own quality improvement program (Nelson et al., 1995).
Report Cards and Performance Standards
Consumer ratings of service industries have been available for many years but have only recently become available for health care. With the emergence of managed care and consideration of competing health plans, purchasers need to make decisions about what benefits they need, the amount of out-of-pocket expenses or copayments that are desired, and the choice of providers and practitioners within a plan or network. In the public sector, purchasers need to make policy decisions on behalf of publicly insured individuals in the context of the local and regional political and economic environments.
A majority of the health care quality information has been geared toward employers and other purchasers, but there is a growing emphasis on providing information that will help consumers select managed care plans that provide quality and an array of services. Quality in these terms is usually measured as patient satisfaction with the services that have been received. Common dimensions include access to care, perceived quality of the contact with the provider, and outcomes of the contact, such as improvements in health status.
One area of controversy has to do with the quality of the data that are used to prepare report cards. Many health plans produce their own report cards as part of a marketing strategy, and without some kind of independent verification of the data, there may be an incentive to misrepresent information. Another major concern has to do with the comparability of data from different plans, because they may have had different benefit structures, different member populations with different levels of risk, and other differences. One approach has been taken by the Pacific Business Group on Health (PBGH), a nonprofit coalition of public and private purchasers. PBGH has developed a model plan design that all members must adopt, information systems are comparable so that performance can be measured in the same ways across plans, and the data are collected and analyzed in a format that can be audited (Brown, 1996).
Contracts for Purchasing Care
The structure of the contract between a payer and a managed care organization and the means for monitoring and enforcing the contract are among the most important ways to influence the quality of care (Essock and Goldman, 1995). Contracts and contract language in the purchasing agreement should specify expectations about benefits and covered services, standards of care, ways of ensuring that the standards and other quality measures are met, and incentives and disincentives associated with the vendor's performance. For example, if a state agency is concerned about the possibility of a managed care organization “dumping” patients with serious mental illness into the public system, the contract could specify that the organization will have to pay a financial penalty for every day that a person covered by the contract spends in a state hospital (Essock and Goldman,
1995). As a positive financial incentive, a contract might include a bonus based on the number or proportion of individuals who experience reduction in symptoms and other positive outcomes.
Some large purchasers, such as the Digital Equipment Corporation and Pacific Business Group on Health, have developed their own set of standards and monitoring guidelines and requirements and include those in their contracts with managed care organizations. Some other purchasers have adopted these standards, but others may in the future require use of the standards developed by the National Committee for Quality Assurance, which are based in part on the American Managed Behavioral Healthcare Association's performance measure set, or the report card developed by the Center for Mental Health Services. These behavioral health performance measurement systems will be discussed further in Chapter 6.
In an effort to control costs and improve efficiency and quality, many states are contracting with managed behavioral health companies. The development of contracts that protect and enhance care for publicly insured individuals is a new responsibility for state agencies, and technical assistance manuals for public purchasers of managed care have been developed by the Center for Substance Abuse Treatment (1994, 1995) and by the Bazelon Center for Mental Health Law (1995).
ETHICAL ISSUES IN MANAGED BEHAVIORAL HEALTH CARE
Quality of care necessarily raises ethical issues. Most ethical issues related to managed behavioral health care are not new or unique to managed care, either medical or behavioral health managed care. Many of these concerns also existed under fee-for-service systems, but public awareness of these concerns has been increasing as managed care has expanded. The intent of this section of the report is to review the most salient ethical concerns in relation to the quality of care. Generally, these issues revolve around confidentiality, patient autonomy, the practitioner-patient relationship, and the patient's right of appeal.
Designating the primary care physician as the coordinator of care and requiring prior authorization for treatment and other case management activities inherent in managed care increase the necessity for sharing medical information. The primary concern about confidentiality under managed care focuses on the claim that there is a greater demand to release confidential patient information in managed care systems than under fee-for-service systems. Information is disclosed when authorization for treatment is sought and when patients are referred from one service provider or practitioner to another. These risks for breach of confidentiality are not new under the managed care system, although they are perhaps
more accelerated in this system because of increased efforts to centrally manage the care.
Patients have increased concerns about confidentiality related to mental health or substance abuse treatment because of their fear of being stigmatized. Who is bound in the confidential relationship and thus obligated to protect the use of or prevent further disclosure of the information? The most relevant element is therefore the obligation of managed care plans to designate explicitly who can release and receive information and the limits to which it can be used. Ethicists agree that insurers, providers, and practitioners have a duty to safeguard the release of sensitive information through policy directives, information system protections, and quality assurance mechanisms (IOM, 1993).
Confidentiality Regulations in Substance Abuse Treatment
A unique aspect of treatment for alcoholism and drug abuse is the presence of federal regulations (42 CFR Part 2) that require that the confidentiality of information about individuals in substance abuse treatment be maintained. The regulations prohibit unauthorized disclosure of patient-specific information and limit the ways in which disclosure can occur legally. The Hughes Act (P.L. 91-616), its reauthorization (P.L. 93-282), and the Drug Abuse Prevention, Treatment, and Rehabilitation Act of 1972 (P.L. 92-255), as amended by P.L. 93-282, stipulate that treatment records are confidential and required the development of federal regulations to govern the disclosure of information from patient records (Legal Action Center, 1988, 1991; Lopez, 1994; NIDA, 1980).
The regulations protect the privacy of individuals entering care and help assure men and women seeking care that their participation in treatment cannot be disclosed without their consent. The requirements are more restrictive than those related to doctor-patient or attorney-client privilege (Legal Action Center, 1991). All substance abuse treatment services that receive federal assistance, tax exemptions, or authorization to conduct business are covered by the regulations. Most treatment programs follow the guidelines developed by the Legal Action Center (1991) to facilitate the disclosure of patient information and maintain compliance with the regulations.
Without special safeguards, the computerized information systems used to record diagnostic and billing information and to share clinical records within a health plan could violate the federal regulations. The confidentiality of patient records and any information about participation in treatment for alcoholism and drug abuse therefore becomes an especially complex issue within the context of managed behavioral health care.
Patient autonomy can be defined as the right of an individual to exercise free will, have choice among options, and be the decision maker in managing his or her health care. Therefore, from this perspective patient autonomy has always had certain limitations. When one seeks care from another, there is an implicit understanding that the practitioner assumes some role in managing the person's health. To the degree that an individual allows payment for his or her health care by a third party, that party becomes a stakeholder in the process and the patient's autonomy begins to be restricted.
Managed care limits the choices that patients have regarding what services are available and who will provide them. This is part of the rationale under which managed care systems were created. The ethical concern is whether the restriction of choice results in limitations that affect the outcome of care. Even to the degree that managed care may mean less care, one cannot presume that this means worse or less effective care, although exposures in the media and litigated cases have occasionally provided evidence that this can occur (e.g., Goleman, 1996).
Individuals have a responsibility to learn as much as they can about their health plans, including the nature of their benefits (Council on Ethical and Judicial Affairs, 1995). Respect for autonomy assumes that a patient is capable of self-determination, but the capacity of an individual patient to make sound decisions that are in his or her best interest is influenced by the nature and course of the illness, as well as by individual personality and preferences. This is true for all illnesses (Povar, 1991).
Thus, the choices made by a patient may not be those recommended by the patient's clinician or family. Disregarding patient preferences by not offering options can have measurable effects on the patient 's compliance as well as the patient's outcome (Povar, 1991). This further complicates the issue of patient autonomy. However, in spite of these factors, patient autonomy and the right to make choices need to be ensured, even though reasonable limitations may exist.
The discussion of patient autonomy leads directly to the issue of the practitioner-patient relationship. In medicine, this relationship has always been considered to be based on trust (Council on Ethical and Judicial Affairs, 1995). Critics on both sides argue about the impact that managed care has on this relationship. Advocates say that a primary care physician maintains, by definition, a principal and ongoing association with the patient, serving as the coordinator of his or her medical care. Opponents of managed care believe that the structure of the system distances a patient from the physician. Large group practices, provider panels, prior authorization requirements, and arbitrary assignment
of a patient to a practitioner or a series of practitioners can erode the practitioner-patient relationship.
There is general agreement that disrupting an established relationship is usually disadvantageous. The ethical question seems to be to what degree is this allowable without having an effect on the effectiveness of care? Do insurers and providers have an obligation to minimize the likelihood of this happening? Are such mechanisms as policy directives, service delivery structures, and quality reviews adequate safeguards and guarantees for preserving the practitioner-patient relationship?
Society's expectations are the ultimate test of the fit of our measures of quality. We believe that creative dialogue about quality with consumers and persons experiencing recovery from mental illness is a professional and ethical requirement that will change and increase with society 's expectations.
American Nurses Association
Public Workshop, April 18, 1996, Washington, DC
The role that patients play in managing their health is a theme common to the ethical concerns of confidentiality, patient autonomy, and the practitioner-patient relationship. Several factors influence what this role can or should be. These include the patient's individual personality, life situation, health history, and functional capacity and cultural background; the nature and course of the illness(es); the effectiveness of health services; and the availability of community support. The manner in which all of these dynamics converge significantly affects the effectiveness of care provided. In the course of events, the decisions made and the outcomes of these decisions can be misunderstood, or can be confusing or disturbing for patients. Patients can feel victimized by the very systems that are supposed to care for them.
To empower patients, they need to receive adequate information regarding choices of treatment and to be able to provide informed consent. Social change and public policy have increased the need to involve patients in their treatment decisions. Health care providers and practitioners, ethicists would agree, have a moral duty to provide systems that empower patients, allow them to be responsible for making treatment decisions, and give them opportunities to appeal decisions made by others on their behalf.
Summary of Ethical Concerns
Addressing the ethical issues in mental health care and addiction treatment is especially complex. This is because of the unique impact that mental illness and addiction have on the reasoning and behavior of individuals and the continuing stigma associated with mental illness and addiction. Much more than physical illness, mental illness and addiction are viewed as social as well as medical problems. The question is not whether managed care should continue in light of these ethical concerns. Rather, it is how managed care must best address and respond to these critical issues.
This chapter has discussed some of the major trends affecting health care delivery. One major trend is the increasing numbers of individuals enrolled in managed care plans, which take a variety of forms with different delivery and financing structures. A second trend is the increasing numbers of individuals in the public sector who are being enrolled in managed care plans, including a large number of individuals with chronic and severe health problems. A third trend is the shift from exclusive concern with the cost of care to increasing interest in the quality of care, which can be described as the overall value derived from expenditures on health care on the basis of evidence of effectiveness and positive outcomes from care.
John Ruskin, a nineteenth century businessman, said something I think helps us to determine where we have gotten in this field. He said: it is unwise to pay too much, but it is worse to pay too little. When you pay too much, you lose a little money. That is all. But when you pay too little, you sometimes will lose everything, because the thing you bought was incapable of doing the thing it was bought to do.
William Dennis Derr
Employee Assistance Professionals Association
Public Workshop, April 18, 1996, Washington, DC
Quality assurance in health care takes many forms, including licensure and certification of providers and practitioners, practice guidelines, report cards, performance measures, and regulatory approaches such as accreditation. Evidence of the effectiveness of different approaches is still preliminary because of the variety
of quality improvement strategies and the complexity of health care. However, the committee believes that there is increasing support and consensus about the importance of quality improvement throughout the health care system.
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