Donabedian's (1966, 1980, 1982, 1984, 1988a, b, c) approach to quality assessment examines structure, process, and outcome. Access is typically considered part of the structural component of quality measurement. The committee, however, has special concerns about access to managed care, particularly for vulnerable and high-risk populations, and believes that a separate discussion about access is warranted.
Managed care reduces the expense of health care, in part, by restricting the use of some services. Gatekeeping, utilization management, and treatment guidelines are designed to ensure that the levels and amounts of care are appropriate for the severity of the clinical condition and to inhibit the delivery of unnecessary amounts or types of services (IOM, 1989, 1992). Sometimes, however, the procedures used to manage costs are perceived as barriers to access rather than as mechanisms that facilitate efficient care. Plans may restrict the choice of providers to only those practitioners who are willing to accept discounted fees and may implement copayments to discourage the overuse of services. Capitated practitioners and health plans, moreover, may have financial incentives to avoid the use of expensive services and to limit the amount of care provided. Access to care therefore becomes a critical issue in the analysis, evaluation, and management of managed care plans.
Managed behavioral health care produces savings in several ways, including paying lower prices to providers; reducing the use of inpatient care, especially for substance abuse treatment; and reducing the length of outpatient treatment. A study of mental health and substance abuse in the Massachusetts Medicaid program found that utilization of care changed in accordance with an incentive struc-
ture that was designed to reduce costly inpatient admissions while allowing more use of less expensive outpatient treatment (Callahan et al., 1994). Typically, however, such incentives are not in place, and there are no protections to ensure that individuals are able to receive the most appropriate care that is available to them. The committee believes that access to care must be monitored carefully to ensure that individuals in need of mental health and substance abuse services receive prompt and appropriate care. Because private insurance and health plans often limit benefits for mental health and substance abuse services and because public systems of care serve individuals with high levels of disability and vulnerability, access to services must be monitored in both systems.
The reasons for monitoring access to care within managed care plans are outlined in this chapter. Current approaches to the measurement of access are also reviewed. Finally, the need for a broader approach to the measurement and evaluation of access is examined.
IMPORTANCE OF ASSESSING ACCESS
Historically, either a lack of coverage for mental health and substance abuse services or limited benefits restricted access to and the utilization of treatment for mental health and substance abuse problems (Frank and McGuire, 1996; McGuire, 1981, 1989; Rogowski, 1992, 1993; Scott et al., 1992). Although some states passed legislation that required that commercial group health care plans include coverage for mental illness and alcoholism, the benefits were limited and many states simply required that coverage be offered (Scott et al., 1992). Services for drug abuse and dependence were rarely specifically included in health plans (Rogowski, 1993), although plans tended to extend coverage for alcoholism treatment to other drugs of abuse.
Even in the public sector, Medicaid coverage for mental health and substance abuse treatment tends to be limited (Horgan et al., 1994; Larson and Horgan, 1994; Solloway, 1992). Copayments have also been used to discourage service utilization. Moreover, a large portion of the population and a disproportionate number of individuals with mental health and substance abuse problems are uninsured and dependent on publicly funded services. Public systems of care limit access through the use of strict eligibility criteria: individuals must be categorically eligible for Medicaid and must usually meet “most-in-need ” criteria for serious mental illness to receive care in state mental health systems. Access to mental health and substance abuse benefits was therefore problematic even before the introduction of managed care.
Even more threats to limit access may exist within a managed care environment. Self-insured employers can design benefits packages without regard to state mandates for mental health and substance abuse coverage. Capitated health plans and practitioners may have incentives to deny access to expensive levels of care and even to deny care (Woolhandler and Himmelstein, 1995). Utilization man-
agement procedures can be used to restrict access to certain levels and types of care and to pressure practitioners to limit lengths of stay (Schlesinger et al., 1996). These practices and incentives not only reduce expenses but also exert both subtle and overt pressures on individuals with mental health and substance abuse problems to leave or disenroll from the plan. Critics of managed behavioral health care plans often focus on the potential for reduced access and undertreatment (Boyle and Callahan, 1995; NCQA, 1996).
The stigma associated with mental illness and substance abuse also contributes to the potential for undertreatment and insufficient access to care (Mechanic et al., 1995). Individuals with mental health and substance abuse problems may be reluctant to publicly acknowledge their illnesses and seek care. In addition, when they seek care for other medical problems, the relevance of mental health and substance abuse problems may not be evaluated. As discussed in Chapter 2, primary care practitioners in general are not trained to identify the need for mental health and substance abuse treatment and may not be comfortable making interventions and referrals if they suspect a problem. Thus, the characteristics of these illnesses increase the susceptibility of individuals with mental health and substance abuse problems to being underdiagnosed and undertreated.
Men, women, and children who suffer from mental illness and substance abuse tend to be vulnerable in several ways. Individuals who have a serious mental illness or a dependence on alcohol and other drugs are likely to have inadequate economic and social supports, may have difficulty in advocating for their own health care needs, and are at high risk of disease, injury, and death. A lack of access to behavioral health services can aggravate their needs for acute and chronic medical care and may increase the cost of health care. More generally, mental illness and substance abuse problems and the costs associated with treating those problems also place large burdens on families, communities, and the criminal justice system (Mechanic et al., 1995). Inadequate care for mental illness and substance abuse increases the strains that families and employers experience and shifts the burden of intervention from the medical system to the criminal justice system and may affect public safety. Access to treatment for mental health and substance abuse treatment therefore has direct implications for employers, communities, and the public authorities for the Medicaid, mental health, substance abuse, and criminal justice systems.
The issue of parity of coverage for mental health and medical care achieved widespread national attention during the summer and fall of 1996, when Congress debated amendments to the Kassebaum-Kennedy bill on job-to-job coverage. The Senate version of the bill included a provision advocating parity of mental health coverage with medical coverage but the provision was dropped from the final version of the bill passed by Congress and signed by President Bill Clinton. House and Senate negotiators later agreed to a compromise version that requires parity for existing lifetime or annual limits but does not mandate mental health services. The provision does not include substance abuse or chemical dependency,
and it exempts small businesses with 2 to 50 employees. The compromise version was passed as part of the annual appropriations bill for the Departments of Housing and Urban Development and Veterans Affairs in October 1996 and additional parity proposals are likely in the future.
In 1993, the Institute of Medicine went on record supporting universal access to insurance and health care (IOM, 1993, p. 7) by saying, “All or virtually all persons—whether employed or not, whether ill or well, whether old or young —must participate in a health benefits plan.” The present committee agrees with this goal and recognizes that the absence of a national strategy for universal coverage means that the responsibility lies with the states.
The committee therefore adopted a broad perspective on access to mental health and substance abuse treatment and prevention services. The committee defines access as the extent to which those in need of mental health and substance abuse care receive services that are appropriate to the severity of their illness and the complexity of their needs. Too often indicators of access reflect merely the availability of services or the delivery of any service rather than the delivery of services that respond effectively to the needs. In fact, an analysis of the measures used to assess access suggests that they often merely reflect prompt attention rather than the amount and level of care delivered.
MEASURES OF ACCESS
Managed behavioral health care organizations, purchasers, and accreditation organizations are using a variety of measures of access. Box 5.1 compares some of the existing measures.
A survey of performance indicators used in mental health facilities, community mental health centers, behavioral group practices, and managed care organizations examined 11 measures of access and assessed current use, appropriateness of use, perceived validity, and measurement feasibility (IBH, 1995). The assessment found that the organizations were most likely to monitor access using utilization and penetration rates: (1) days and number of visits per 1,000 population, (2) average length of stay, and (3) number of sessions per episode of care. More than 90 percent of the respondents rated measures of patient satisfaction with access, waiting time for emergency visits, and geographical convenience as useful measures. Patient satisfaction, however, was perceived as the least valid measure, and only 55 percent of the respondents monitored geographical convenience; waiting time was rated as useful by 70 percent of the respondents. Finally, managed care organizations rated telephone access highly. The overall impression is that relatively little attention has been given to the development of systems and measures to monitor access.
Analysis of the access standards proposed for the National Committee on Quality Assurance's Health Plan Employer Data and Information Set version 3.0 (HEDIS 3.0), and of those currently used by Digital Equipment Corporation and
BOX 5.1 Sample Access Standards and Measures for Behavioral Health Care HEDIS 3.0 (NCQA, 1996)
Availability of mental health and chemical dependency providers
Intensive alternatives to inpatient care
Patient encounters per 1,000 covered lives for intensive alternatives to inpatient care by age and diagnostic category.
Cost data for severely and persistently mentally ill (for patients with psychotic or bipolar diagnoses only)
Call abandonment rate
The average call abandonment rate.
National Association of County Behavioral Health Directors
(The Evaluation Center@HSRI, 1996)
Percentage of individuals receiving services who live within a 15-mile radius or a 30-minute travel time.
Waiting time for appointments
Percentage of individuals referred for mental health services who are seen within a specified period of time, given the urgency of the request (emergent = 8 hours, urgent = 48 hours, routine = 7 days).
Percentage of individuals indicating that services were easily obtainable in a self-report interview or survey.
Program provides 24-hour access to professional help.
the American Managed Behavioral Healthcare Association (AMBHA) confirm that initial impression. Prompt attention is measured and assessed more often than the fit between the service provided and the level of need. HEDIS 3.0, for example, only requires monitoring of appointment waiting time, telephone access time, and the number of mental health and chemical dependency providers available to plan members (NCQA, 1996). Digital Equipment Corporation's (1995) standards reflect HEDIS 3.0 but specify the performance expected. AMBHA's (1995) Performance-Based Measures for Managed Behavioral Healthcare (PERMS 1.0), perhaps because the AMBHA membership specializes in the management of mental health and substance abuse services, disaggregate penetration and utilization rates by age and diagnostic category but do not assess the overall need for services and whether the services are appropriate for the needs. Thus, the current measures of access used in commercial arenas appear to be insufficient for monitoring access in a more comprehensive fashion.
The National Association of County Behavioral Health Directors recommended a broader set of access measures in their review of performance outcome indicators (The Evaluation Center@HSRI, 1996). Their measures reflect the broader mission of public systems of care and include cultural competencies training for staff, consumer reports of language and cultural barriers to using services, cultural similarities between staff and consumers, geographic access to care, and consumer reports that services were accessible and convenient, in addition to measures of waiting time. These measures of access begin to monitor some of the more subtle barriers to care and should be more widely disseminated and adopted. There is still no information, however, on the level of need for care in the enrollee population and the degree to which the need is being met.
NEED AND ACCESS
The committee believes that purchasers and plan managers should be encouraged to expand their monitoring of access. The indicators promoted for use in county behavioral health programs illustrate strategies for monitoring more subtle influences on access. Population measures of need, however, must still be developed and integrated into the access monitoring systems. A managed care program, for example, might be satisfied with a penetration rate of 10 percent for mental health and substance abuse services. If information on need, however, suggested that 20 percent of plan members were in need of services, a 10 percent penetration rate would be less satisfactory.
Population-based measures of health status and needs assessment, in fact, are major components in the development of effective integrated systems of care (Shortell et al., 1994). Close linkages are required with public health and social service systems so that health status can be assessed and monitored. Managed systems of care must improve their ability to assess the needs of their enrollees and collect primary data on the populations that they serve, especially those at great-
est risk for health and mental health and substance abuse problems: individuals in poverty, racial and ethnic groups, and others with special needs (Shortell et al., 1994).
The measurement of access is an extremely important area of concern for purchasers and for consumers. No valid and reliable technology exists to measure access, which is assessed in a variety of ways: access to clinicians, to initial and follow-up appointments, to appointments with clinicians of choice, at time of day of choice, and so on. Satisfaction with access is one important source of information, but additional measures need to be conceptualized, developed, tested, and implemented.
NEEDS OF SPECIAL POPULATIONS
Considering the fit between service need and access also means taking into account variations in need among different groups, particularly differences associated with gender and race or ethnicity. The issue of fitting special services to special needs is particularly relevant to ethnic and gender subgroups. Utilization of services in general and of particular types of services varies by gender and ethnic groups according to treatment and national survey data, but it is not known if this is due to discrimination (e.g., selective screening at admission, including insurance criteria that exclude those without proper health profiles), to a lack of interest and denial of the problem, or to the fact that appropriate services that would attract such groups are not made available to them.
Different population groups have different problem profiles, are differentially represented, and have different treatment needs and issues related to access. For example, women's substance abuse treatment needs often differ from men's (De Leon et al., 1982; Reed, 1987), particularly because of their higher rates of childhood sexual and physical abuse and victimization (Wallen, 1992) and also because women may have fewer economic resources and social supports available (Anglin et al., 1987; Harrison and Belille, 1987; Weisner, 1993; Weisner and Schmidt, 1992). Drug addicts who are pregnant have been identified as a group that could become involved in the prevention of chronic medical conditions in children (Weisner, 1996).
Ethnic and Racial Differences in Substance Abuse
It is also important to consider ethnic and racial differences when examining availability and access to services. Ethnic minorities are overrepresented in the public system and are underrepresented in the private system, and this poses special considerations as the public system increasingly contracts with managed care organizations. Rates of need for services differ by age, socioeconomic status, and
gender within ethnic groups (Anglin et al., 1988; Caetano and Herd, 1988). For example, African American men have higher rates of drug problems than do African American women, and the men and women also differ with regard to type of drug used (McNagny and Parker, 1992; NIAAA, 1990; NIDA, 1991).
Studies of Hispanic populations have found similar important differences by gender and type of drug (Caetano and Mora, 1988; De La Rosa et al., 1990; Hser et al., 1987). For example, use of illegal drugs and the utilization of drug treatment facilities varies widely with the type of drug used across and within the subgroups of the Hispanic population (De La Rosa et al., 1990). To underline the vast heterogeneity within ethnic groups, the rates of drug use are also affected by factors such as acculturation for Hispanics (Caetano, 1983, 1987, 1993a; De La Rosa et al., 1990) and by migration patterns and urban versus rural location for African Americans (Herd, 1989, 1990, 1994).
As with health care in general, differences in the availability of mental health and substance abuse treatment, as well as type of program, are affected by the geographic distribution of services, particularly urban versus rural status (IOM, 1990). There is also evidence that availability differs by state, since the balance between private and public sectors in the services that they provide, need levels, general availability, and program type vary greatly by state (IOM, 1990; Weisner et al., 1995a).
In addition to different courses of service in the public- and private-sector systems, large disparities have been found in the type of service provision across the states, especially in the allocation of services; per capita funding (public and federal combined) ranges from $23.54 to $2.36 across the states (IOM, 1990). The extent of private services across the states is not well correlated with the amount of public services. Neither is there any relationship between need in a state (measured by cirrhosis mortality or per capita consumption) and the amount of service provided (IOM, 1990).
There is some variation across states in terms of program philosophy and the type of public substance abuse treatment program that is funded (e.g., the use of 28-day programs by the public sector in Minnesota and the support of social model programs in the public sector of California). It has also been suggested that the merging of alcohol and drug treatment programs may affect access to treatment in that the balance of treatment capacity for primary alcohol abuse treatment compared with that for a drug problem may shift (Weisner, 1992). Similar concerns have been expressed with regard to the merging of alcohol and drug treatment within mental health systems.
Combined drug and alcohol use is increasingly characteristic of substance abusers (Clayton, 1986; Hubbard, 1990). In addition, many chronic substance abusers use more than one drug and also have diagnosable mental health problems. In this regard, the Epidemiologic Catchment Area data found the proportion of individuals who met the criteria for a lifetime prevalence of alcohol dependence to be 24 percent of those meeting the criteria for schizophrenia, 52
percent of those with antisocial personalities, 12 percent for those with any anxiety disorder, 12 percent for those with phobia disorders, 22 percent for those with panic disorders, and 17 percent for those with obsessive-compulsive disorders (Regier et al., 1993). For these individuals, the entry point to the specialized alcohol and drug treatment system is often through the mental health system or emergency rooms and sometimes the criminal justice or welfare systems.
Although young drug and alcohol users are at risk for chronic problems, their problematic use patterns are appropriately addressed through prevention or early intervention treatment services. Although rates of substance abuse are greatly affected by type of substance, gender, and ethnicity (Anglin et al., 1987; Hser et al., 1987; Kandel and Yamaguchi, 1985), roughly 30 to 40 percent of those who begin using alcohol or drugs early continue the use past adolescence and become chronic users (Robins and Przybeck, 1985). Those who do continue are at great risk of developing future problems. They are most likely to enter the specialized treatment system through the criminal justice or educational systems or emergency rooms rather than through the primary health care system. A system monitoring chronicity might track high-risk status for adolescents (ages 12 to 17) with alcohol and drug use problems coming into contact with the systems listed above.
Young and middle-age adults who are at risk for chronic problems often began using drugs or alcohol during adolescence and are currently dependent. Others begin using drugs or alcohol later as adults, but meet the criteria for severe dependence. Both groups are most likely to enter the treatment system through the workplace and employee assistance programs, the criminal justice system for alcohol or drug-related arrests, the mental health system (for comorbid problems), or emergency rooms for alcohol- and drug-related injuries. They can be identified by screening for long use or the severity of their dependence and the frequency of their polydrug use. Medical complications may or may not be present.
Middle-age or elderly individuals who have substance abuse disorders generally have long drinking and/or drug use histories and meet the criteria for severe dependence. The symptoms of individuals in this group also are often characterized by the presence of chronic medical conditions and often by repeated admissions for alcohol or drug abuse treatment. This group may also enter treatment programs through the criminal justice system through a variety of alcohol- or drug-related arrests, including arrests for public intoxication. They may also enter the system through workplace programs, although many may no longer be employed, or through emergency rooms and the primary health care system. Relapse management for chronic abusers is an important part of treatment as well as the rehabilitation and aftercare stages of treatment (Curry et al., 1988; Leukefeld and Tims, 1986, 1990; Marlatt and Gordon, 1985).
A range of services needs to be available for these groups of individuals and treatments may need to be repeated. Longer or more intensive treatment stays may also be required for chronic substance abusers. Ideally, individuals would be assessed, and appropriate levels and modalities of services could be provided. These
services are likely to involve the specialized treatment system as well as the primary health care system. Different assessment tools are available, including the Addiction Severity Index (McLellan et al., 1992) and the Patient Placement Criteria developed by the American Society on Addiction Medicine (CSAT, 1994).
MEASURING ACCESS TO SERVICES WITHIN MANAGED CARE ORGANIZATIONS
National data sets and data sources available at the community level can be used to assess the prevalence of substance abuse problems and the services needed within health plans. Information on the chronic medical conditions resulting from alcohol and drug use or abuse is mainly available from hospital discharge surveys and death certificates (NIAAA, 1990). The major strength of these measures is their availability at the county level. The causes of death that the National Institute on Alcohol Abuse and Alcoholism (NIAAA) argues are actual measures of chronicity are cirrhosis (including chronic liver disease and cirrhosis and portal hypertension), alcohol dependence syndrome, and alcohol-related psychoses.
Data are also available on the deaths due to alcohol-related incidents, such as drunk driving. In using such alcohol-related mortality measures, NIAAA notes that factors in addition to mortality rates should be considered (NIAAA, 1991). Such indicators include the size of the population; the existing treatment capacity, including the geographic dispersal of that capacity; the amount of financial support per treatment modality; the level of urbanization; the sociodemographic characteristics of the population, such as ethnicity and age; and the existence of waiting lists for treatment programs. NIAAA claims that the data can be used to project population estimates of need by linking data on current resources with these types of data listed above in multivariate models (NIAAA, 1991 ). The major usefulness of adapting large data systems to measure chronicity is their potential usefulness in providing ratios of the number of cases to the overall prevalence, adapted for differences in population characteristics.
It is important to note the differences between the results drawn from data collected from the general population and those collected from populations in treatment systems (Corty and Ball, 1986; Rounsaville and Kleber, 1985; Weisner et al., 1995b). Although both data sources are crucial to estimating need and to developing systems for monitoring the care of chronic substance abusers, they cannot answer the same questions. Systems that track the prevalence of substance abuse in the general population provide both prevalence estimates and the need for services in the population as a whole. Data from treatment agencies provide information on trends in the group receiving the services and the needs of the individuals in that group.
The preferred data for measuring prevalence and monitoring the effectiveness of managed care organizations in responding to substance abuse problems involves epidemiologic surveys. However, these are expensive, and it is not fea-
sible for many managed care organizations to conduct such surveys. However, with managed care organization membership data on age, sex, and basic socioeconomic status, it is possible to make reasonable estimates of need for services within the membership from several surveys conducted every few years. The rates of alcohol and drug abuse problems by age, sex, and socioeconomic status are quite consistent, particularly when they are adjusted by region of the country.
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 (AMBHA, 1995; Digital Equipment Corporation, 1995; NCQA, 1996). 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) (IOM, 1990).
The nature of managed care and the nature of mental health and substance abuse problems combine to make access a 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 who access the available care promptly and early in their illness episodes may require less intensive care, and with appropriate continuing support, they may be less likely to experience relapses.
Access enables quality, which is a treatment plan focused on recovery. Quality informs innovation, reducing to the irreducible minimum the time between the discovery of a treatment or service that works and the implementation of that service in the field.
State of Rhode Island
Public Workshop, April 18, 1996, Washington, DC
Measures of access, however, must go beyond telephone answering time and must 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 plan administrators must begin to assess the adequacy of current access to their
plans. Information on the ambient level of need in a health plan is required to truly assess the adequacy of the plan in meeting the demand and need for care.
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