Managing Managed Care: Quality Improvement in Behavioral Health: Summary (1997)

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Summary INTRODUCTION With great speed and a considerable amount of controversy, managed care has proclucec3 dramatic changes in American health care. At the end of 1995, 161 million Americans more than 60 percent of the total popu- lation belonged to some form of managed health care plan (HIAA, 1996~. The movement into managed care has been especially rapid for the treatment of mental health and substance abuse (alcohol and drug) prob- lems, also known as behavioral health problems. Behavioral health prob- lems are common: every year, an estimated 52 million Americans have some kind of mental health or substance abuse problem (see Table ~ ). At the end of 1995, the behavioral health benefits of nearly 142 million people were managed, with 124 million in specialty managed behavioral health care programs and 16.9 million in a health maintenance organiza- tion (HMO) (Open Mincis, 1996~. HMOs, preferred provider organizations (PPOs), point-of-service plans, and other forms of managed care networks, such as managed behav- ioral health care organizations, differ in their organizational structures, types of practitioners and services, access strategies, payment for practi- tioners, and other features. Their goals, however, are similar: to control costs through improved efficiency and coorclination, to reduce unneces- sary or inappropriate utilization, to increase access to preventive care, and 1

2 MANAGING MANAGED CARE TABLE 1 Estimated Annual Prevalence of Behavioral Health Problems in the United States (Ages 15-54) Behavioral Health Problems Prevalence No. of People (percent) (millions) All behavioral health problems (i.e., mental disorders, alcoholism, and drug addiction) Any mental disorder Any substance abuse or dependence (i.e., alcohol and illicit drugs) Both mental disorder and substance abuse or dependence 29.5 22.9 .3 4.7 52 40 20 8 NOTE Prevalence data have been collected from the National Comorbidity Survey (NCS), a congressionally mandated survey designed to study the comorbidity of substance use disorders and nonsubstance use-related psychiatric disorders in the United States. The survey was administered by the staff of the Survey Research Center at the University of Michigan between 1990 and 1992. NCS surveyed 8,098 noninstitutionalized participants with a structured psychiatric interview con- ducted by lay interviewers using a revised version of the Composite International Diagnostic Inter- view (CIDI). CIDI is a structured diagnostic interview based on the National Institute of Mental Health's (NIMH's) Diagnostic Interview Schedule, which can be used by trained interviewers who are not clinicians (Kessler et al., 1994). SOURCE Kessler et al. ( 1994) and SAMHSA ( 1995 ). to maintain or improve the quality of care (IOM, 1996a; Miller and Luft, 1 994). Both private-sector employers and public-sector agencies (Meclicaicl anc3 state mental health anc3 substance abuse authorities) have turned to managed behavioral health care companies to control costs anc3 improve quality anc3 access for mental health anc3 substance abuse care. Traclition- ally, insurance benefits for mental health anc3 substance abuse care have been more limited compared with benefits for physical health, anc3 for mental health anc3 substance abuse care there also have been few alterna- tives to hospitalization. In the late 1980s, the majority (70 percent) of funds for mental health care spent by Meclicaic3 anc3 private insurance went for inpatient care, leacling many researchers, clinicians, anc3 advocates to question the imbalance anc3 to search for policy changes. Only the introduction of managed care arrangements has led to a sig- nificant shift away from costly and often unnecessary inpatient stays to a more appropriate range of outpatient anc3 community-basec3 care. In sum, behavioral health care offers purchasers the potential to spread existing resources farther by paying for less intensive (anc3 less expensive) treat

SUMMARY 3 ment strategies that can help patients return to a reasonable level of func' tioning, such as being able to return to work or school (England anc3 Vaccaro, 1991 ). The controversies in managed care are less about the goal of cost re' Suctions anc3 are more about the ways in which cost reductions are achieved. Methods of cost control include authorizing only certain practi' tioners who are uncler contract to provide services to an enrolled popular tion, reviewing treatment decisions, closely monitoring high~cost cases, reducing the number of clays for inpatient hospital stays, anc3 increasing the use of less expensive alternatives to hospitalization (Iglehart, 1996; Shore and Beigel, 1996~. In the committee's view, managed care strategies are not inherently harmful anc3 can be appropriate anc3 helpful, as in the shift from inpatient to outpatient care, the aciclitional supervision for complex cases, anc3 ap' plications of stanciarcis based on best practices. However, certain activities of companies that provide behavioral health care, such as limiting or clef eying services that may be needed or appropriate, adding barriers to access to care such as increased copayments for outpatient visits, anc3 addling gatekeepers who change the practitioner~patient relationship, can have an adverse impact on patient outcomes (Mechanic et al., 19951. All of our purchasers, including government and private purchasers, are looking at setting up outcomes and performance measures. Everybody has their own idea about what's a good outcome. Unless there can be some sort of consensus about what that means, ~ think increasingly we're going to see plans that are going to be ineffective at measuring outcomes. Michae/ Jeffrey Wi//iam R. Mercer, /nc. Public Workshop, May 77, 7996, /n/ine, CA The overall impact of managed care on the quality of health care is difficult to determine. For example, managed care has many structures, anc3 comparisons across organizational forms (e.g., HMOs versus PPOs) are difficult. In abolition, the quality of health care is difficult to measure

4 MANAGING MANAGED CARE anc3 define because of the complexity of health care anc3 because of the variety of opinions about quality. The Institute of Medicine (IOM) has ciefinec3 quality of care as "the degree to which health services for incli- vicluals anc3 populations increase the likelihood of ciesirec3 health outcomes anc3 are consistent with current professional knowledge" (IOM, 199Oa, p. 21~. Each component of this definition has variations health services (e.g., primary care anc3 specialty drug abuse, alcoholism, anc3 mental health treatment in different practice settings, including hospital- based anc3 office-basec3 practices anc3 hearth centers), inclivicluals (e.g., differences among children, adolescents, adults, anc3 seniors, as well as gender cliffer- ences), populations (e.g., cultural differences anc3 differences between ru- ral anc3 urban populations), anc3 outcomes (e.g., cure, relapse prevention, anc3 return to functioning). The combinations are virtually unlimited. The challenge of accountability studies is how we build report cards that report consistent, credible, and verifiable data back to the patients and the people who are trying to pick which HMO or PRO they're going to join. Ran c/a// Mac/ry Utilization Review Accrec/itation Commission Public Workshop, May 17, 1996, Irvine, CA Public interest in quality of care is keen, anc3 purchasers are interested in information that can help them make decisions on the value anc3 effec- tiveness of different managed care options. Several approaches have cle- velopec3 to assess the quality of care: accreditation, licensing anc3 certifica- tion, creclentialing and privileging, practice guiclelines, performance measures, report carcis, anc3 other means (see Figure ~ ). Many of these ap- proaches are unfamiliar to most consumers, but HMO ratings, aciaptec3 from product anc3 service rating systems such as those cievelopec3 by Con' sumer Reports, reach a wide audience through national magazines such as Time, U.S. News arid World Report, anc3 Neqvsqueek anc3 in national news- papers including The Wall Street fourrral, The New York Times, anc3 USA Today. When new measures of health care quality such as report carcis are aclclecl to the traditional approaches, primarily accreditation and licensure

SUMMARY EXTERNAL: ACCOUNTABILITY Accreditation Licensure Specialty Certification Peer Review Audits Utilization Management Utilization Review Media Reports s INTERNAL: IMPROVEMENT Clinical Protocols Clinical Outcomes Data Clinical Supervision Provider and Clinician Profiling Performance Measures Consumer Satisfaction Appeals and Grievance Procedures Promptness of Paying Claims BOTH Managed Care Contract Language Standards 1 1 1 Guidelines 1 Performance Measures 1 | Indicators l 1 ~1 Report Cards FIGURE 1 Framework for quality assessment. The figure displays a wide array of activ- ities that can have an impact on the quality of care. Impact may vary depending on the level of responsibility for quality of care within an organization, the regulatory mecha- nisms that apply, the nature and extent of the relevant outcomes research base, and other factors.

6 MANAGING MANAGED CARE of practitioners and facilities, quality assessment becomes a complex patch- work of mechanisms. Federal, state, anc3 local governments, accreditation organizations, managed care organizations, purchaser coalitions, consumer groups, professional organizations, anc3 the media are actively involved in providing information on the quality of health care. Some of these efforts are collaborative, but some are competitive. Overall, the picture is incom- plete, inconsistent, anc3 inadequate for making truly informed decisions about the quality of health care services. To those who are responsible for purchasing care, the absence of consensus on quality measurement makes it very difficult to make decisions. When you think about it, every organization be it a managed care organization, an insurer, a hospital, an integrated delivery system, whatever has huge financial systems that literally aggregate and track hundreds if not thousands of financial transactions. On the quality side, we pull ~ O charts and do a review. John Bartlett American Managec/ Behaviora/ Hea/thcare Association Public Workshop, April is, 1996, Washington, DC DESCRIPTION OF THE STUDY In the spring of 1995, the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse anc3 Mental Health Services Ac3- ministration (SAMHSA) in the U.S. Department of Health anc3 Human Services (DHHS), asked the IOM to convene an expert committee that would consider issues related to quality assurance anc3 accreditation in managed behavioral health care. As part of SAMHSA's Managecl Care Initiative, CSAT was the lead agency in the effort, with aciclitional sup- port from SAMHSA's Center for Mental Health Services (CMHS) and Center for Substance Abuse Prevention (CSAP). A ~ 7-member committee was chosen to carry out this effort. The mem- bers had expertise with national accreditation processes anc3 procedures, publicly anc3 privately financed managed care organizations, employee as

SUMMARY 7 sistance programs, corporate and public purchasing of mental health and substance abuse services, public and private medical administration, and health services research. The committee also included individuals who had experience as direct consumers of behavioral health care or as family members of consumers. The charge to the committee was to develop a framework to guide the development, use, and evaluation of performance indicators, accredita' tion standards, and quality improvement mechanisms. The framework could then be used to assist consumers and other purchasers of publicly and privately financed care with the purchase of the most effective man' aged behavioral health care at the lowest appropriate price. The committee identified a variety of stakeholders as the audience for the report. These included accreditation organizations, managed care com' panics, federal and state governments, community~based treatment orga' nizations, health services researchers, practitioners, consumers, and other interested parties. In carrying out this task, the committee operated on a clear premise: the ultimate goal of the work was to improve the quality of care for people with behavioral health problems. The committee met five times between February and July 1996. To gather information to assist in its deliberations, the committee convened two public workshops. The first workshop was held in Washington, DC, in April 1996, and included 25 speakers representing national accredita' tion organizations, the behavioral health industry, professional associa' tions, and consumer and advocacy groups. The second workshop was held in Irvine, California, in May 1996, and included nine speakers represent' ing accreditation organizations, a benefits consulting firm, a purchasing cooperative, and the behavioral health care industry. An additional seven speakers were invited to the committee's fourth meeting in June 1996 to discuss consumer issues specific to children, older adults, and seriously mentally ill individuals; quality improvement activities in the military health care system; and culturally appropriate care for Native Americans, Asian Americans, and Hispanic Americans. In addition to these workshops and presentations, liaison panels were formed with more than 150 representatives of national accreditation groups, national professional associations, consumer and advocacy groups, managed care industry groups, and federal and state agencies. Members of the liaison panels were invited to attend the public workshops and re' ceived information regarding the study at various stages (e.g., meeting dates and workshop agendas). More than 40 members of the liaison panels also provided written statements for the committee's consideration.

8 MANAGING MANAGED CARE The committee reviewed the available medical, psychosocial, anc3 health services research on the outcomes anc3 effectiveness of treatment in managed care. The committee also sought other empirical findings to in- form its deliberations, including current activities anc3 surveys in the man- agec3 behavioral health care industry, including those performed by the American Managed Behavioral Healthcare Association (AMBHA) anc3 the Institute for Behavioral Healthcare, as well as documents anc3 reports from federal agencies such as the CSAT anc3 CMHS, the National Insti- tute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse anc3 Alcoholism (NIAAA), anc3 the Health Care Financing Administration (HCFA). The committee also reviewed descriptions of five accreditation orga- nizations: the Rehabilitation Accreditation Commission (formerly the Commission on Accreditation of Rehabilitation Facilities) (CARF), the Council on Accreditation of Services for Families anc3 Children (COA), the Joint Commission on Accreditation of Healthcare Organizations (ICAHO), the National Committee for Quality Assurance (NCQA), anc3 the Utilization Review Accreditation Commission (URAC). In abolition, the committee reviewed the following previous reports by the IOM: Con- trollir~gCosts arid Char~gir~gPatier~t Care? The Role of Utitizatiorr Marragemer~t ~1989), Medicare: A Strategy for Quality Assurance ~199Oa), Ctirlical Prac- tice Guidelirres: Directions for a New Program (199Ob), Broaderrir~g the Base of Treatment for Alcohol Problems ~ ~ 990c), Treating Drug Problems ~ ~ 9903), Employmer~t arid Health Benefits ( 1993 ), Primary Care: America's Health ire a New Era (1996a), anc3 Pathways of Addictiorr: Opportunities ire Drug Abuse Research ~ 1996b). However, the committee also recognized that many of the stucly's most important questions could not be answered solely by searching the avail- able clinical anc3 policy research anc3 health care industry literature. To provide a context for this report, the committee clevelopec3 a set of prin- ciples that is based on empirical evidence, but that also relies on a consic3- eration of issues that may not have been examined empirically. These prin- ciples are reflections of a current uncierstancling of strategies for improving the quality of care anc3 also reflect ethical concerns that have emerged through the incliviclual committee members' professional anc3 personal ex- periences in the delivery anc3 study of health care.

SUMMARY STATEMENT OF PRINCIPLES 9 i. Helping to improve the quality of life for inclivicluals, families, anc3 those responsible for the legal anc3 financial circumstances of those inclivicluals anc3 families should be the heart of all efforts to improve the quality of behavioral health care. 2. Because treatment is effective for mental health anc3 substance abuse problems, it is an essential part of health care anc3 should be access sible to all. Behavioral conditions should be viewed as clinical conditions, both in the provision of (anc3 access to) preventive interventions anc3 treat' ment anc3 in the requirements for quality anc3 patient satisfaction. 3. Activities to improve the quality of health care should be based on evidence of effectiveness whenever possible. Every group among the stakeholclers consumers, practitioners, purchasers, managed care com' panics, accreditation organizations, anc3 other groups must share respon' sibility for the quality of treatment. Commitment to improving quality should be inherent in any agreement to provide or receive care. 4. The expense of successful anc3 appropriate treatment for mental health anc3 substance abuse problems can be a barrier anc3 a burden, put' tiny inclivicluals anc3 families at substantial financial risk. However, un' treated behavioral health problems are also costly to inclivicluals, families, businesses, anc3 the rest of society. Thus, providing insurance coverage against the financial risks of behavioral health problems anc3 guaranteeing access to treatment can be justified on grounds of fairness as well as effi' ctency. 5. Managed care technologies offer an opportunity to increase ac' cess to preventive interventions ancl to control costs without imposing special limits ancl excessive cost~sharing. However, managed care can also bring risks of unclertreatment ancl concerns about quality. 6. Vulnerable anc3 clisablec3 populations are potentially most at risk from the failures in the managed behavioral health care market. Particular l ~ attention should be paid to the impact of managed care on such popula' Lions, which include chilclren, seniors, people from diverse cultural back- grouncis, people who live in rural anc3 other medically uncierservec3 areas, people who live in poverty, people who have developmental ancl other disabilities, people with co~occurring clisorclers (e.g., depression anc3 alco' holism), ancl people who have the most severe forms of mental illness ancl aclcliction. 7 Quality improvement ancl accreditation are two important tools

10 MANAGING MANAGED CARE that can be used to protect anc3 improve the quality of care. In general, quality mechanisms should be used to improve performance anc3 reward best practices. 8. This committee adopts the definition of quality of care bevels open by another TOM committee: "the degree to which health services for inclivicluals anc3 populations increase the likelihood of clesirec3 health out' comes anc3 are consistent with current professional knowledge" (IOM, 199Oa, p. 211. 9. Quality of care includes several components. These include (~) a real opportunity for the person being treated to have a reasonable range of practitioners anc3 treatment options from which to choose, anc3 to pro' vine informed consent (by the person being treated or by a clesignatec3 representative, the approval of, anc3 agreement with, the decision or ac' Lions taken by the providers; (2) the protection of confidentiality anc3 privacy rights, balanced with the need to share clinical information to improve the coordination of care; (3) a ciemonstratec3 respect for the cul' rural context of the incliviclual anc3 community being served; anc3 (4) an emphasis on functional assessments, such as a return to work or school, as measures of success. 10. Behavioral health problems require an array of preventive anc3 treatment services that are coorclinatec3 into a continuum of care that in' tegrates worksites and schools with all parts of the medical treatment sys' rem, as well as with community~basec3 services. Accreditation and Quality Assurance Many methods are being used to protect consumers anc3 improve the quality of care in this environment of rapid change. The charge anc3 focus of this committee was on managed care, particularly with two prominent strategies: accreditation of managed care entities anc3 the use of perfor' mance indicators. However, the committee recognized that other issues, such as licensure of practitioners anc3 state inspection anc3 certification of provider agencies, play critical roles in consumer protection. Thus, the committee also consicierec3 complementary strategies that can aid in con' sumer protection anc3 quality improvement, such as consumer choice of health plans anc3 better integration of outcomes research anc3 clinical prac' trace.

SUMMARY 11 Will accreditation markedly change the quality of patient care? It may make the system better. It may make the system appear more efficient. But the principal question is, what happens to the patient? Mark Parrino American Methac/one Treatment Association Public Workshop, April is, 7996, Washington, DC This approach was required, in the committee's view, given the inter- relatec3, significant, anc3 complex changes that are uncier way anc3 the vul- nerability of inclivicluals who suffer from serious mental illness anc3 aciclic- tions to alcohol anc3 other drugs. There is increasing evidence that treatment for mental illness, substance abuse, anc3 other behavioral health problems is effective anc3 that its effectiveness is generally comparable to that of treatment in other parts of medicine. In the committee's view, therefore, robust steps are essential to address consumer protection and quality improvements, particularly through improved accreditation and performance measurement systems. Although many of the committee's concerns about quality are unique to behavioral health care, any study of accreditation anc3 other quality assurance strategies also has relevance to the general health care system. The processes of accreditation anc3 quality assurance are fundamentally the same in the primary care and specialty sectors, and the role of primary care practitioners contributes to the evaluation anc3 delivery of behavioral health care. Furthermore, all sectors of the health care delivery system are responding to the same clemancis from policy makers anc3 the public for accountability anc3 cost-effectiveness. Framework for the Study and the Report To provide a framework for the study, the committee aciaptec3 the work of Aveclis Donabeclian, a distinguished public health economist and mem- ber of the TOM who has written several books anc3 articles on the assess- ment anc3 monitoring of quality. Donabeclian has ciescribec3 three interre- latec3 ways to uncierstanc3 anc3 measure quality: structure, process, anc3 outcomes. Measures of structure include the types of services available, qualifications of practitioners, staffing patterns, adherence to building and

2 MANAGING MANAGED CARE other cocles, anc3 other administrative information. Process measures of quality focus on procedures anc3 courses of treatment, such as numbers of individuals servecl; on the appropriateness of the care; and on ongoing efforts to maintain quality, such as practice guidelines anc3 continuous qual- ity improvement activities. Outcome measures of quality include health status changes after treatment anc3 consumer satisfaction with the care proviclec3, as well as short-term or intermediate outcomes. Many of these terms were used by the presenters in the public workshops, anc3 thus the committee believes that inclivicluals who work in the field of performance measurement are already generally familiar with this type of approach. To prepare the full report, the committee aciaptec3 Donabeclian's ap- proach to aciciress the past, present, anc3 likely future of health care quality improvement in relation to managed care, particularly to managed behav- ioral health care. Chapter 1 is intenciec3 to provide a context for the report by describing the committee's consumer protection approach to quality measurement, including the statement of principles used in approaching this report anc3 presented earlier in this Summary. Chapter 2, Trencis in Managed Care, describes current influences across the spectrum of health care delivery, including quality measurement activities anc3 changing roles of purchasers. In Chapter 3, Challenges in Delivery of Behavioral Health Care, quality measurement issues unique to managed behavioral health care are aciciressec3, including the history of separate anc3 distinct systems of care. in Chapter 4, Structure, the current delivery systems for behavioral health are clescribec3; these include substance abuse, mental health, anc3 primary care in both the public anc3 private sectors, as well as separate systems for children, seniors, the military, anc3 Native Americans. Chapter 5, Access, discusses general concerns about access, measurement of access in the private sector, anc3 specific concerns about vulnerable anc3 high-risk populations in the public sector. (Access is viewed as a structural factor in the Donabeclian framework, but the committee chose to consider access variables in a separate cliscussion.) Chapter 6, Process, provides an overview of accreditation and quality improvement activities in their current forms. Chapter 7, Outcomes, re- views what is known from research about treatment outcomes. This chap- ter is supplemented by two papers that appear in Appenclixes B and C, respectively: Thomas McLellan anc3 his colleagues Mark Belcling, James McKay, David Zanis, anc3 Arthur Alterman aciciress questions of substance abuse outcomes research, anc3 Donald Steinwachs discusses outcomes re

SUMMARY 13 search in mental health. In Chapter 8, Findings anc3 Recommendations, the committee's concerns are summarized anc3 specific recommendations are presented for future steps to aciciress those concerns. (These also appear in their entirety at the end of this Summary.) TERMINOLOGY USED IN THIS REPORT Managed care takes a philosophical approach different from traditional fee-for-service health care, anc3 its terminology has influenced discussions about quality of care in health economics, public policy, anc3 the media. In these contexts, the term consumer is used to refer to an incliviclual who receives care, who purchases care directly, or who selects among health plans purchased on his or her behalf by an employer or by another entity, such as a professional association or union (the selection is also known as "consumer choicely. Consumer protection anc3 consumer satisfaction, originally applied in the context of industry products, now can refer to quality assurance anc3 quality improvement in the health care system. The use of the term consumer is sometimes controversial in primary care anc3 medical specialties, particularly psychiatry, anc3 also in the men- tal health specialties of psychology, social work, marriage anc3 family therapy, and counseling. Many clinicians view the term as placing undue emphasis on the purchase of health care rather than on the relationship with a practitioner who delivers the care. For example, the 1996 report of the {OM Committee on the Future of Primary Care used the term patient anc3 slid not refer to consumers. As {glehart has ciescribec3 (1996), the ap- plication of managed care principles means that practitioners begin to share clinical clecision-making with payers, insurance plan managers, as well as with consumers, anc3 this is difficult for many practitioners. In the course of its deliberations, this committee used the term patient in the context of a therapeutic relationship while an incliviclual is receiv- ing care from a clinician, but used the term consumer more broadly to refer to inclivicluals in most circumstances, including inclivicluals who are mak- ing purchasing clecisions, who are evaluating report carols, or who have already received treatment anc3 are in recovery. This usage is consistent with that of the DHHS, including the Agency for Health Care Policy anc3 Research (AHCPR), HCFA, anc3 SAMHSA. This usage is also consistent with that of four of the accreditation organizations whose activities anc3 stanciarcis were reviewed for the report. The term behavioral health, used throughout this Summary anc3 in the full report, also is a creation of the managed care industry. The term was

4 MANAGING MANAGED CARE clevelopec3 in private~sector managed care companies in the mic3~1980s to describe mental health anc3 substance abuse (the abuse of alcohol anc3 other drugs). This term also is controversial, on the grounds that a variety of treatment modalities (e.g., behavioral, cognitive, anc3 psychodynamic modalities) are used, anc3 also on the grounds that the clisorclers them' selves may be physiological or organic rather than simply behavioral mani' Gestations of dysfunction. Box ~ summarizes the terms used in this report. The committee recog' nizes anc3 respects the variety of uses of these terms, including those used by other {OM committees. In the rapidly changing health care environ' meet, these terms seemed to this committee to be the most applicable for this study of quality assurance in managed behavioral health care. TRENDS IN MANAGED CARE Market forces are creating dramatic shifts in the structure anc3 conduct of business in the health care delivery system. Employers, government agencies, anc3 other purchasers of health care have become increasingly aggressive in ciemancling competitive prices from suppliers of health ser' vices. The response to the new strategies in health care buying has been an acceleration in the growth of managed care organizations, including man' aged behavioral health care plans (see Tables 2 anc3 3~. Patients were not always aware of the procedures and how to utilize their benefits. Who reads that? ~ mean, do you know what your benefits are? None of us does. So on the back of their authorization letter, we included the members rights and responsibilities as well as questions that were most commonly asked. Peter Panzarino Vista Behaviora/ Health Public Workshop, May 17, 1996, Irvine, CA

SUMMARY 15 BOX 1 Terminology Used in This Report Behavioral health: managed care term applied to mental health and sub- stance abuse care and services. Client: an individual who is being treated for mental health or substance abuse problems in a social or rehabilitation setting (e.g., a residential treatment program) or in the private practice of a psychologist, social worker, marriage and family therapist, or counselor. Clinician: an individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients (IOM, 1 996a, p. 33~. The term is typically applied in medical set- tings. Consumer: an individual who is, has been, or may in the future be re . . . calving care or services. Patient: an individual who is cared for by a clinician for purposes of diag- nosis, treatment, or preventing illness or for maintaining recovery from illness. The term is usually applied in primary care and specialty medical settings, including psychiatric practice. Practitioner: an individual who delivers clinical, rehabilitation, or psycho- social treatment to individuals in medical, clinical, or social settings. Provider: a program, facility, or organization that delivers health care. Purchaser: a group such as an employer, unit of government, associa- tion, or coalition that negotiates for and buys health care on behalf of a specified group, generally to cover specific benefits and services at re- duced prices. Stakeholders: individuals and groups for whom the cost, availability, ac- cessibility, or quality of care hold direct implications, including individuals who receive care and their families, practitioners, public and private pur- chasers, managed care companies, accreditation organizations, and pol- icy makers.

16 TABLE 2 U.S. Health Insurance Data (in millions), 1992-1995 MANAGING MANAGED CARE Population Description 1992 1993 19941995 Total population 251.7 256.9 259.3264.3 Insured populations 212.8 215.7 219.6223.7 HMO enrollment 41.4 45.2 51.158.2c Specialty MBHC enrollments 78.1 86.3 102.5110.9 Uninsured population 38.9 41.2 39.740.6 aHMO enrollment and specialty managed behavioral health care (MBHC) enrollment are in- cluded in the category "Insured population" to illustrate their relative proportions. Due to potential double counting, they should not be added. bSpecialty MBHC has been defined as an entity managing fixed behavioral health, mental health and chemical dependency treatment benefit budgets on capitated, risk-based, or performance-based contracts (Open Minds, 1996). The term excludes public programs and most provider-sponsored integrated delivery systems (Stair, 1996). C1995 projection as of June 1996. SOURCES EBRI (1996), GHAA (1996), HIAA (1996), Open Minds (1996), and Stair (1996). Employers have always tried to evaluate the value of health care. To our employer groups, that is defined as a change in health status plus satisfaction, divided by cost. Catherine Brown Pacific Business Group on Health Public Workshop, May 17, 1996, /n/ine, CA Of the 161 million Americans who belonged to some form of man- agec3 health care plan at the end of 1995, approximately 60 million were enrolled in HMOs (see Figure 2~. Increasing numbers of inclivicluals in the public sector (Meclicaic3 and Meclicare) are being enrolled in managed care plans, including a large number of inclivicluals with chronic and severe health problems. Evidence supports the ability of managed care plans to control costs, but there is little evidence of the impact of managed care on quality. However, purchasers, including employers and public agencies, are increasingly interested in the quality of care. Their emphasis is in' creasingly on the overall value clerivec3 from expenditures on health care based on evidence of effectiveness and positive outcomes from care.

SUMMARY 17 There was a young person who was not successful on any kind of inpatient treatment or intensive outpatient treatment or any of the programs. And we finally got him into a group home situation. The health plan paid for it and then they did a cost-benefit analysis. And they found that not only was it clinically effective, but it was incredibly cost effective. Susan Go/c/man John Hancock Public Workshop, April is, 1996, Washington, DC The increased use of managed care approaches in behavioral health care presents both opportunities anc3 risks. For example, the use of case management to coordinate care for inclivicluals with complex conditions that are costly to treat can improve care anc3 control costs, making it more feasible to improve insurance coverage anc3 to integrate private anc3 public systems for substance abuse, mental health, anc3 primary care. Conversely, managed care approaches that emphasize cost control over quality of care can reduce access to care anc3 result in shifting the costs of care for needier inclivicluals to an overburclenec3 public system. If we really focused on patienVclient-driven, assessment-based, clinically driven treatment in the most efficient and effective way, based on accountability and data, that would take care of costs. Davic/ Mee-Lee American Society on Ac/c/iction Mec/icine Public Workshop, April is, 7996, Washington, DC CHALLENGES IN DELIVERY OF BEHAVIORAL HEALTH CARE The most unusual aspect of the care and financing system for behave ioral health services is the presence of a distinct, substantial, complex, anc3 publicly financed delivery system that serves as a safety net. Thus, public

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SUMMARY 60 U. 50 o - - ~ 40 ._ - Q 30 o o at, 20 E Z 10 o 21 CO oo o CM ~o Cal ~ rid ~ao Go oo Do Do ~CJ) ~Cal At) ~ Year FIGURE 2 Number of HMO Enrollees, 1976-1995. SOURCE: HIAA (1996~. services are available for those with public insurance, as well as for those who have private insurance. Public services are funciec3 through a large number of categorical programs aciministerec3 by different agencies, creat- ing both duplication and gaps in service, and almost always with different eligibility requirements. Fragmentation in funding leacis to fragmented ser' vice delivery. In the private sector, we're really talking about, by and large, episodic users of service. In the public sector, we're talking about another population who are really continuous users of service. Our systems of care are really very different. Robert Egnew Nationa/Association of County Managec/ Behaviora/ Hea/thcare Officials Public Workshop, May 17, 1996, Irvine, CA

22 MANAGING MANAGED CARE A significant portion of the public care system for inclivicluals with the most disabling conditions extends beyond health care services to rehabili' tative and support services, including housing, job counseling, literacy, and other programs (also known as "wraparouncl" or "enabling" services). The coordination of these services requires collaborative anc3 cooperative relationships among many agencies, including public health, mental health, social services, housing, education, criminal justice, anc3 others. Even for those who have private insurance, most of these services are not covered, anc3 collaborations between most private behavioral health care companies anc3 the public sector are just beginning to develop. We think we can bring a more comprehensive focus to the ideas of what is necessary looking beyond narrow definitions of medical necessity to areas of human necessity, which could include having basic income, having help in getting housing, and ongoing support services. Elizabeth Ec/gar Na lion a / A //ian ce for th e Men ta //y /// Public Workshop, April id, 7996, Washington, DC Another challenge is that much behavioral health care, perhaps as much as half of all episodes of care, is proviciec3 in primary care settings, not in specialty programs. Despite clinical practice guiclelines, continuing education courses for professionals, and other training programs, primary care providers tend to unclercliagnose anc3 unclertreat depression, substance abuse, anc3 other behavioral health problems. This is changing, but there is a great need to improve the quality of behavioral health care cleliverec3 in primary care settings, to better coordinate the care delivered in primary care anc3 specialty sectors, anc3 to increase all practitioners' awareness of new anc3 effective treatments. The dynamics of the three interrelated sectors privately funclec3 pri' mary anc3 specialty care anc3 public systems are complex anc3 also highly idiosyncratic from state to state, community to community, and plan to plan. Any approach to reform of behavioral health services or to the prob' lem of accountability must reckon with these factors.

SUMMARY STRUCTURE 23 We encourage physicians to have enough skill to be able to know when there is a problem and something needs to be done, and then enough self-awareness to know whether they are the ones to do it or somebody else should. Lin c/a Breso/in American Mec/ica/Association Public Workshop, April is, 1996, Washington, DC The behavioral health care delivery system involves a complex com- bination of public anc3 private financing, as well as public anc3 private prac- titioners anc3 treatment settings. Analysis of the structure of the behav- ioral health care system thus requires a review of the public anc3 private service systems for both substance abuse anc3 mental illness. We have a public mental health system that helps us, that delivers both care and services and helps us to be stable in our own communities, despite having disabling mental illnesses. Ray Bric/ge Northern Virginia Consumers Association Public Workshop, April is, 7996, Washington, DC Public-sector services are financed either with state and federal appro- priations or through Meclicaic3 anc3 Medicare coverage. In the private sec- tor, systems of care are typically financed by employers and have different structures, but they co-exist and often overlap with public sector services. For example, public clinics may contract with private companies to cle- liver specified health services. Workplace service organizations (e.g., em- ployee assistance programs) and other managed behavioral health care ser- vice organizations began in the private sector, but are beginning to develop contracts with public mental health anc3 substance abuse agencies.

24 MANAGING MANAGED CARE Children with emotional disorders are in all kinds of families wealthy, middle class, poor, some with insurance, some with no insurance, some eligible for public sector financing and programs. Sybi/ Go/c/man Georgetown University Public Workshop, April is, 7996, Washington, DC Federally supported service systems clevelopec3 by the U.S. Department of Defense (DoD) anc3 the U.S. Department of Veterans Affairs (DVA) share characteristics of both the private- anc3 public-sector systems of care but represent separate anc3 distinct service systems. In abolition, service systems also exist for distinct populations: children, seniors, anc3 Native Americans. The large number of inciepencient service delivery systems serving different populations through different funding streams compli- cates the assessment of quality. The variety anc3 complexity also can in- hibit attempts to develop anc3 implement comprehensive stanciarcis to im- prove the quality of care. Managed behavioral health care plans serving children and their families face the added challenge of providing family-centered services that need to interface with the multitude of systems that serve children. Michae/ Faenza Nationa/ Menta/ Health Association Public Workshop, April lo, 1996, Washington, DC Historically, the development of services for the treatment of alcohol- ism, drug abuse, anc3 mental illness reflects prevailing political currents anc3 a persistent ambivalence toward full recognition of these illnesses as medical rather than moral or criminal justice problems. Although alco- holics anc3 drug afflicts were frequently acimittec3 to mental health institu

SUMMARY 25 tions and sought care from psychiatrists and psychologists, poor quality and ineffective services could result from the lack of understanding of ad- diction. After completing withdrawal, patients who were chemically de- pendent were difficult for the mental health system to care for appropri- ately. Similarly, individuals with serious mental illness received poor care in alcoholism and drug abuse treatment programs. As a result, the service systems evolved and matured relatively independently. The history of ten- sion between the service systems continues to slow attempts at full inte gratlon. Drug and alcohol problems are pervasive in our society, whether we address them or not. And ~ could sum it up this way: they don't just fade away. They go to another funding stream. Gwen Rubinstein Lega/Action Center Public Workshop, April is, 1996, Washington, DC However, direct and insufficiently planned applications of private- sector managed care models to public 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 ex- clude social and support services and, because they emphasize acute care, tend to have little experience in the management of chronic and disabling conditions. The tensions over cost controls have increasingly focused con- cerns about cost-containment efforts on quality issues such as the follow- ing: . qualifications of and consumers' geographic access to a compre hensive range of providers; . prevention of avoidable illness and provision of timely and fo cusec treatment interventions; availability of services, based on urgency of need; courtesy, convenience, and comfort of services; compassion and kindness of care; · competence of providers to institute the most appropriate evalu ations and treatments, which would result in the use of services that would

26 MANAGING MANAGED CARE put the patient at least risk anc3 that would provide the best health status outcome; and · administrative efficiencies of health care services that promote quality through effective communications, consumer anc3 provider ecluca- tion, decision support anc3 quality management, treatment coordination, anc3 other systems. 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 . . . c Inlclan. Lin c/a Kaplan Nationa/ Association of A/coho/ anc/ Drug Abuse Counselors Public Workshop, April is, 1996, Washington, DC ACCESS Access to health care is closely associated with insurance coverage, anc3 access to behavioral health care was problematic even before the in trocluction of managed care. Historically, insurance coverage for mental health anc3 substance abuse treatment has been more limited than cover age for physical illness. Discussions of parity between mental health anc3 physical coverage have only recently reached beyond the advocacy com munity anc3 specialty sectors anc3 into congressional legislation. 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. Dona/c/ Ga/amaga State of Rhoc/e /s/anc/ Public Workshop, April is, 1996, Washington, DC

SUMMARY 27 Managed care organizations, i: nclucling managed behavioral health care organizations, tend to measure access anc3 accessibility in terms of utilization (e.g., the number of enrollees who used specific services, num- ber of visits to particular practitioners), anc3 telecommunication (e.g., on- holc3 time anc3 call abandonment rates). Purchasers, however, may prefer to view access more broadly anc3 include reductions in barriers to care anc3 improvements in benefits (e.g., reductions in copayments, increases in hours of service, reductions in travel time, anc3 expanciec3 eligibility for specific services or populations). Consumers, in turn, may view access in terms of their own experiences in being able to receive services from pro- viclers of their choice. The nature of managed care anc3 the nature of mental illness anc3 sub- stance abuse combine to make access a crucial issue. Well-clevelopec3 pub- lic anc3 private health care anc3 behavioral health care plans will promote access to mental health anc3 substance abuse services. Enrollees that access care promptly anc3 early in their illness episode may require less intensive care and with appropriate continuing support may be less likely to have a relapse. A culturally competent system of care values diversity, has the capacity for cultural self- assessment, is conscious of the dynamics inherent when cultures interact, has institutionalized cultural knowledge, and has developed adaptations to diversity. Grace Wang Association of Asian Pacific Community Heath Organizations Presentation to the Committee, June 29, 1996, Washington, DC Measures of access need to be developed to reflect the real and per- ceivecl barriers to care including cultural clifferences, geographic clistance, inconvenient locations anc3 times, anc3 care that is less intensive than neeciec3. With such new measures, it would be far easier for the purchasers of health care plans and the plan administrators to assess the adequacy of their current access. Information on the level of need in the health plan is

28 MANAGING MANAGED CARE needled to truly assess the adequacy of the plan in meeting the clemanc3 anc3 need for care. PROCESS Process measures of quality focus on the procedures anc3 courses of health care, such as treatment procedures or the number of inclivicluals served; on the appropriateness of the care received; anc3 on ongoing efforts to maintain quality, such as practice guidelines anc3 continuous quality improvement activities. In the committee's view, the quality measurement process also includes the process of ensuring quality, through accreclita' tion, performance measurement, anc3 other activities. In general, measurement of the quality of health care is driven by clif' ferent forces in the private anc3 public sectors. In the private sector, quality measurement is a reflection of the requirements of the accreditation pro' cess anc3 is increasingly a response to the clemancis of employers anc3 other purchasers through contracting, report carcis, anc3 other means. In the pub' kc sector, performance measurement is the primary tool of accountability for spending public funds on health care. We have always had managed care. Until now, we have had what ~ would call doctor managed care. We are shifting to corporate managed care. The third wave is what ~ call self-managed care, or self- determination, having a say in the important decisions of one's life. Danie/ Fisher Nationa/ Empowerment Center Public Workshop, April is, 7996, Washington, DC Some private payers, such as the Digital Equipment Corporation, have cievelopec3 their own stanciarcis for HMOs anc3 other managed care organ)' zations providing care and are also urging contracted organizations to col- lect anc3 publicly report information on their performance. Public agencies are also developing performance stanciarcis, often in the context of man' aged care initiatives, such as those under way at the AHCPR, HCFA, and SAMHSA. The National Association of State Mental Health Program

SUMMARY 29 Directors has worked closely with the AMBHA in the development of performance measures that are being field tested by several groups, incluc3' ing the NCQA. The interest in quality is reinforced by consumer ciemanc3 anc3 empow' erment, professional ethics, legal anc3 regulatory interpretation of citizens' rights, anc3 attempts by employers to increase the value of their health care clollars anc3 to satisfy their employees in a competitive health care market' place. For public purchasers who are accountable for public funds, it is important to demonstrate that health care has value anc3 is worth the in' vestment of taxpayers. This is particularly challenging given the patch- work of competing accreditation organizations, the need for more public information on criteria for good performance, anc3 the complexities in cle' fining anc3 measuring clinical outcomes. John Ruskin, a nineteenth-century businessman, said something ~ 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. Wi//iam Dennis Derr Employee Assistance Professionals Association Public Workshop, April is, 7996, Washington, DC Accreditation Organizations Accreditation is an important means of assessing the quality of health care. The committee reviewed accreditation materials from five organize' tions that accredit behavioral health plans, programs, anc3 services: CARE, COA, ICAHO, NCQA, anc3 URAC. This section briefly describes each of the organizations.

30 MANAGING MANAGED CARE The Rehabilitation Accreditation Commission (formerly the Commission on Accreditation of Rehabilitation Facilities) (CARF) CARF accredits programs that serve inclivicluals with disabilities anc3 others who need rehabilitation. The organization was cievelopec3 in 1966 through efforts of the American Rehabilitation Association anc3 the Asso- ciation of Sheltered Workshops. In CARF's first 2 years, it received ac3- ministrative support from ICAHO, anc3 the two organizations are clevel- oping a "recognition initiative" that eventually will recognize the other's accreditation stanciarcis anc3 thus eliminate the need for dual accreclita tion. Everyone is talking about "vital signs" for the behavioral health field. Tim S/aven Rehabilitation Accrec/itation Commission Public Workshop, May 17, 1996, Irvine, CA CARF currently accredits more than 11,000 programs in the United States anc3 Canada, including alcohol anc3 drug programs, mental health programs, anc3 community-basec3 rehabilitation programs that are prima- rily clesignec3 for the chronically anc3 persistently mentally ill. CARF has a consumer-centerec3 philosophy that actively encourages consumer in- volvement in assessing community neecls, planning services, participating in governance activities, anc3 collaborating in the development of incli- viclual treatment plans. CARF also requires that programs have a plan to reduce barriers to care, including cultural, architectural, attitudinal, anc3 other barriers (Slaver, 1996~. Council on Accreditation of Services for Families anc] Children (COA) COA was founded in 1977 and currently accredits about 1,000 behav- ioral health programs anc3 3,000 social service programs in the United States and Canacla. COA has developed standards for more than 50 ser- vices, including outpatient mental health anc3 substance abuse services, clay treatment, foster care anc3 clay care for children, services for people

SUMMARY 3 with developmental disabilities, services for victims of domestic violence, adoption services, vocational anc3 employment services, anc3 others. COA has developed a set of core standards that apply to all organiza- tions that it accredits, such as financial management, quality assurance, anc3 record keeping, as well as service-specific stanciarcis, such as foster care, residential care, anc3 so on. The behavioral health accreditation overlaps somewhat with those of CARE anc3 ICAHO, but most of the other ser- vices are not aciciressec3 by any other accreditation organization. Also, in contrast to the other accreditation organizations, the programs accreclitec3 by COA are largely community-basec3 programs more closely related to a social services than to a medical model of treatment. There should be a broad commitment to quality and to independent accreditation as the preferred system to measure quality, and there should be freedom of choice for providers among a range of accreditors who meet certain established criteria. Juc/ith Hines Presic/ent, Counci/ on Accrec/itation of Services for Families anc/ Chi/c/ren Public Workshop, May 17, 1996, /n/ine, CA loins Commission on Accreditation of Healthcare Organizations (ICAHO) ICAHO is the oldest anc3 largest of the accreditation organizations. In 1951, the Joint Commission on Accreditation of Hospitals (ICAH) was formed in cooperation with the American College of Surgeons, the Ameri- can College of Physicians, the American Medical Association, anc3 the Canadian Medical Association. The new organization formalized hospital stanciarcis that had been uncier development since the 1920s anc3 1930s by the American College of Surgeons. In the 1970s, ICAH began to develop aciclitional accreditation programs for psychiatric facilities, substance abuse programs, community mental health programs, anc3 ambulatory care facili- ties. In 1987 the name was changed to ICAHO to reflect the new activi- ties anc3 to anticipate a new activity, accreditation of managed care orga- nizations (SAlC, 19951.

32 MANAGING MANAGED CARE Accreditation of HMOs is now a relatively small proportion of ICAHO's accreditation activities. ICAHO, however, has accreditation guidelines for networks, including inciepencient practice associations, in' tegratec3 health care delivery systems, HMOs, managed care organizations, physician~hospital organizations, preferred provider organizations, pro' vicler~sponsorec3 networks, anc3 specialty service systems (ICAHO, 1996~. Another set of accreditation guidelines aciciresses mental health, chemical ciepenciency, anc3 mental retarciation/cievelopmental disabilities services. We believe that the full evaluation of an organization has to combine knowledge of current outcomes with the standards-based information that lets you know whether you are going to be able to predict future outcomes from the current outcomes. Pau/ Schyve Joint Commission on Accrec/itation of Hea/thcare Organizations Public Workshop, April is, 7996, Washington, DC National Committee for Quality Assurance (NCQA) NCQA was formed in 1979 by two managed care associations, the Group Health Association of America anc3 the American Managed Care anc3 Review Association (now merged anc3 renamed the American Asso' elation of Health Plans). The original purpose of NCQA was to perform quality care reviews for a former federal agency, the Office of Health Main' tenance Organizations. From the beginning, NCQA established collabo' rative relationships with industry, including large employers such as Xerox anc3 GTE, insurers, such as Prudential, anc3 managed care plans, such as Harvard Community Health Plan (now Harvard Pilgrim Health Plan) anc3 Kaiser Permanente. In 1989, with a grant from the Robert Wood Johnson Foundation, NCQA began to develop a performance monitoring system now known as HEDIS. The first version, known as HEDIS i.0, was released in 1991, HEDIS 2.0 was released in 1993, and HEDIS 3.0 was released in the sum' met of 1996. NCQA has worked in collaboration with HCFA to develop a Meclicaic3 version of HEDIS, which was released in duly 1995, anc3 in the

SUMMARY 33 spring of 1996 NCQA released a set of behavioral health performance measures for testing, based on the performance measurement system (PERMS) developed by AMBHA. We know that there is competition in the health care marketplace today. ~ don't think anybody doubts that. But it is very much a price-driven competition. And that, we think, is very dangerous to the quality of care that patients are receiving. Margaret O'Kane Nationa/ Committee for Quality Assurance Public Workshop, April is, 7996, Washington, DC Now in its third evolution, HEDIS 3.0 is a voluntary reporting set of managed care quality measures that have evolved over the past 5 years uncler the aegis of NCQA, but with inputs from a broac3 range of experts from a variety of public anc3 private organizations. Although only one spe- cific behavior measure has been part of earlier reporting sets (ambulatory follow-up after hospitalization for a major affective clisorcier), a number of other measures have recently been proposed as a test set that will promote the refinement of these measures over time anc3 the possible evolution of some measures toward the next HEDIS reporting set. Although HEDIS data collection is not required for NCQA accreditation, managed care organizations regularly institute HEDIS measures. Utilization Review Accreditation Commission (URAC) URAC was formed in ~ 990 after a series of meetings with the Ameri- can Managed Care anc3 Review Association anc3 utilization review inclus- try representatives inclicatec3 that there was a need for stanciarcis for utiliza- tion review anc3 an inciepencient accreditation organization. URAC currently accredits the utilization anc3 quality management systems of 150 managed care programs that provide services for more than 120 million inclivicluals. URAC also works closely with state regulators to aciciress man- agec3 care regulatory issues, anc3 nine states accept URAC accreditation in lieu of licensure. URAC has implemented a Network Accreditation Pro

34 MANAGING MANAGED CARE gram and will be implementing a Workers' Compensation Utilization Management Accreditation program. When you get to issues like report cards, we can't verify our data. No one shares common definitions. If you can't get the HMOs to agree on the definitions, how are vou Coins to net the practitioners to agree? , ,= ,= ,= Ran c/a// Mac/ry Utilization Review Accrec/itation Commission Public Workshop, May 17, 1996, Irvine, CA OUTCOMES Defining outcomes for behavioral health problems is difficult. First, there are important differences among alcohol, drug, and mental health problems. The same outcomes should not necessarily be expected for each drug of abuse, for example, heroin versus alcohol, or for every person with a substance abuse problem, for example, a pregnant woman, an adoles- cent, and a person with dual diagnoses of mental health and substance abuse problems. The same is the case for mental health problems: out- comes differ by diagnoses (e.g., mild versus major depression or chronic schizophrenia) and depend on the characteristics of individuals (e.g., for children, adolescents and adults). A second issue affecting the selection of outcomes measures has to do with the actual goals of treatment and the lack of consensus about what is considered successful treatment. A fundamental issue in the substance abuse field is whether treatment goals should be directed toward absti- nence versus improvement. On the whole, alcohol treatment programs are oriented to an abstinence model rather than one of controlled drink- ing or improvement. Political considerations related to the management of illicit substances have played a large part in shaping treatment goals for chronic substance abusers. As a consequence of these strong ideological stances, some of the treatment interventions with proven efficacy (e.g., methadone maintenance with heroin addicts and controlled drinking strategies with carefully selected populations) are not often found in man- aged care treatment systems and therefore cannot be included in current managed care outcomes studies.

SUMMARY 35 For mental health problems, the goals of treatment cliffer according to the diagnosis, the severity of the illness, anc] past responses to treatment. Treatment generally begins with a comprehensive assessment that results in an incliviclualizec] treatment plan. In many cases, full recovery from a mental health problem can be expected, with an incliviclual returning to his or her former level of functioning. Treatment also may have the goal of controlling symptoms or preventing relapses among those with recurring episodes of a clisorcler, such as depression. Improvements in functioning, rather than a complete return to functioning, may be the goal for those with severe anc] chronic clisorclers such as schizophrenia. Improving qual- ity of life by facilitating access to social services (e.g., through case man- agement) may also be a goal, particularly for patients with severe clebilitat- ing anc! chronic mental clisorclers. Finally, the avoidance of violence may be a goal, such as when people with suicidal or homicidal tendencies are restrained in a heavily supervised setting such as a hospital or lockec] nurs- ing facility. Aciclitional goals could include an improver] ability to live in- clepenclently in the community or an ability to maintain employment in a supervlsec . setting. ~ believe we ought to build clinical information systems that as a routine part of operations collect reliable, valid data about important domains. John Bartlett American Managec/ Behaviora/ Hea/thcare Association Public Workshop, April is, 7996, Washington, DC Thus, measurement of treatment outcomes for behavioral health treat- ment is complex. However, outcomes research is key to improving the evidence base for treatment effectiveness. It can help to provide explicit direction in the identification of performance indicators associated with gooc! outcomes for different patient characteristics, types of treatment pro- grams, anc! types of manager! care organizations. In their current forms, performance indicators are not specific for particular organizational char- acteristics (e.g., whether the care is cleliverec] in a staff moclel HMO or a hospital-basec] outpatient clinic), or clinical characteristics (e.g., whether the approach is ten sessions of cognitive psychotherapy or a brief interven

36 MANAGING MANAGED CARE tion by a primary care physician). Also, there is a lack of consensus of clinical judgment in regard to the definitions of outcome (e.g., abstinence versus risk reduction). Purchasers are not waiting for conclusive outcomes research to help them make decisions on the value and effectiveness of different managed care options. However, much needs to be done to make outcomes research directly relevant to the delivery and/or management of the delivery of services and to link findings from outcomes research with the develop' ment of practice guidelines, performance measures, and accreditation ap' preaches. Future methods of quality assessment will need to bridge the domains of research and practice and will need to provide more direct input into the development of accreditation and other assessment strafe' gies. FINDINGS AND RECOMMENDATIONS Managed care is increasingly being used throughout the health care system, and the variability in approaches to managed care is also increas' ing. Managed care methods are growing at a faster rate in the behavioral health care sector than in the rest of the health care system because of their demonstrated ability to control costs in private health plans and be' cause states are turning to managed care as a strategy to control Medicaid costs. Furthermore, because of this rate of change and because of the unique structure of mental health and substance abuse care (e.g., the ex' istence of substantial publicly paid systems at the state and local levels), ensuring consumer protection and quality improvement are important challenges. The increased use of managed care approaches in behavioral health care presents both opportunities and risks. For example, the use of case management to coordinate care for individuals with complex conditions and conditions that are costly to treat can improve care and control costs, making it more feasible to improve insurance coverage and to integrate private and public systems. Conversely, managed care approaches that emphasize cost control over quality of care can reduce access to care and can shift the costs of care for needier individuals to an overburdened pub' kc system. Many interested parties are using a variety of methods to pro' tect consumers and improve the quality of care in this environment of rapid change. The charge and focus of this committee are on managed care, although the committee recognizes that other issues such as licensure

SUMMARY 37 of practitioners anc3 state inspection anc3 certification of provider agencies play critical roles in consumer protection. Furthermore, in its focus on managed care, the committee has been particularly concerned with two prominent strategies: the accreditation of managed care entities anc3 the use of performance measurement systems. At the same time, it has consign erec3 complementary strategies that can aid in consumer protection anc3 quality improvement, such as consumer choice of health plans anc3 better integration of research anc3 practice. This comprehensive approach is required, in the committee's view, given the interrelated, significant, anc3 complex changes that are uncier way anc3 the vulnerability of inclivicluals who suffer from serious mental illness anc3 afflictions to alcohol anc3 other drugs. The committee believes that there is increasing evidence that treatment for mental health anc3 substance abuse problems is effective anc3 that its effectiveness is generally comparable to that of treatment proviciec3 in other areas of medicine. The committee also believes that robust steps to aciciress consumer protection and quality improvements are essential, particularly through improved accreditation anc3 performance measurement systems. The committee clevelopec3 a set of findings anc3 recommendations in 12 areas: structure anc3 financing; accreditation; consumer involvement; cultural competence; special populations; research; workplace; wraparound services; children anc3 adolescents; clinical practice guidelines; primary care; anc3 ethical concerns. The following section sets out the committee's recommendations in these 12 areas. Each set of recommendations is pre' ceiled by the findings that led the committee to make the recommence Lions. In many cases, the findings build on crosscutting themes from test)' many, research, anc3 the committee's deliberations. 1. STRUCTURE AND FINANCING Findings · Historically, the structure anc3 financing of treatment for mental health anc3 substance abuse problems have been inherently problematic. Insurance coverage for mental health anc3 substance abuse care has been limited anc3 frequently has not covered the prolonged treatment that con- sumers and families need to address complex problems. · The separate publicly~financecl health care system creates incen' fives for the private sector to limit benefits anc3 thus to undermine the basic purpose of insurance; that is, to provide protection for large losses.

38 MANAGING MANAGED CARE Costly care is often shifted to the unclerfinancec3 public system, a process that is sometimes called "clumping." . Traditionally, the health care system inhibits access to care anc3 tolerates poor quality of care, anc3 thus contributes to poor outcomes. · The problems of reclucec3 access anc3 increased cost shifting may be aggravated by the use of managed care approaches that focus exclu- sively on reducing costs. High-quality managed care, however, can provide tools to con- trol costs in an integrated system. For example, case management for high- cost treatment can improve access to appropriate treatment while control- ling costs. Existing measures anc3 indicators are inadequate for use as evi- clence of clumping, skimming, and cost-shifting. · Historically, the categorical anc3 fragmented nature of public funding has contributed to fragmentation in service delivery. A recent trenc3 is to combine Meclicaic3 funds with other state anc3 local public funds in the financing of public systems. · The fundamental problems in mental health anc3 substance abuse care cannot be fully aciciressec3 without changing the structure anc3 financ- ing of the system anc3 attending to the problem of the separate public anc3 private sectors of care. Recommendations i.! The reform of systems of care financed by states anc3 counties must: ~ ~ ~ recognize current aspects of private health care in those states anc3 counties anc3 (2) consider the design anc3 development of mechanisms to inhibit cost-shifting. i.2 Payment arrangements that reduce incentives to unclerserve in- clivicluals with behavioral health conditions should be encouraged. i.3 The reform of state anc3 local systems through the use of man- agec3 care should incorporate a recognition of anc3 responsiveness to the unique needs of consumers served by public systems. i.4 Accreditation organizations, when appropriate, anc3 purchasers should develop criteria anc3 guidelines that: (~) recognize anc3 measure clumping, skimming, anc3 cost-shifting; anc3 (2) specify rewards for organi- zations, groups, and individuals that provide appropriate care and penal- ties for those that do not.

SUMMARY 39 i.5 Purchasers should ensure continuity of care for consumers when managed care contracts are awarciec3 to different provider organizations. 2. ACCREDITATION Findings The wide array of consumer anc3 quality protections includes ac- creclitation, performance measurement, clinical practice guidelines, state licensure, anc3 contract requirements. Some of these functions overlap. · Accreditation of managed care plans by inciepencient national bodies is an important anc3 powerful tool of consumer protection anc3 qual- ity improvement in health care anc3 behavioral health care. · Accreditation of service delivery organizations, such as hospi- tals, is well clevelopec3, but accreditation of managed care plans is in its infancy. In the field of managed behavioral health care, accreditation alone is not sufficient to guarantee high-quality care. Currently, multiple competing organizations perform measure- ment, reporting, anc3 accreditation functions in the health anc3 behavioral health care sectors. In the behavioral health care area, the Rehabilitation Accreditation Commission (CARF), Council on Accreditation of Ser- vices for Families anc3 Children (COA), Joint Commission on Accreclita- tion of Healthcare Organizations (ICAHO), National Committee for Quality Assurance (NCQA), anc3 Utilization Review Accreditation Com- mission (URAC) all play roles in accrediting managed care plans that cover mental health anc3 substance abuse care. The American Managed Behavioral Healthcare Association (AMBHA), NCQA, the Substance Abuse anc3 Mental Health Services Administration (SAMHSA), anc3 a number of corporate buyers (e.g., Digital Equipment Corporation) have also clevelopec3 performance rating systems. . Accreclitation organizations compete for accreditation business on the basis of their credibility with payers, providers, anc3 consumers. Benefits consultants and other consultants are advising corpo- rate purchasers anc3 state agencies on procurement, contracting, anc3 other aspects of accountability. This is a significant new inclustry. · Data collection is an intricate part of the assessment of quality of care. Many of the data currently collected are internal, not valiciatec3 by external sources, and may not be relevant to outcomes of care. · Accreclitation tends to focus on measures of the structure and

40 MANAGING MANAGED CARE process of care rather than on measures of clinical outcomes. However, examples of movement in the direction of outcome measurement can be found, such as consumer satisfaction surveys anc3 measures of clinical ap- propriateness. Variability exists in utilization review (a formal assessment of the necessity for services anc3 their appropriateness anc3 efficiency), which can be clone on a prospective (precertification), concurrent, or retrospec tlve basis. . In public systems of mental health anc3 substance abuse care, uninsured anc3 publicly insured inclivicluals can often access a greater se- lection anc3 intensity of benefits for behavioral health care than are avail- able to inclivicluals with private insurance. Federal anc3 state government agencies sometimes require ac- creclitation anc3 specify which accreditation organization's stanciarcis will be accepted. This process is known as granting an accreditation organiza- tion "cieemec3 status." Thus, the organization is "cieemec3" to act in the public interest. Deeming is not clone extensively in health care but is com mon in other sectors, such as in the construction industry. . Quality improvement methods have great potential but are still in preliminary stages for mental health anc3 substance abuse services. Ex- isting behavioral health performance measurement systems have used clif- ferent strategies in their development with varying degrees of consumer involvement. Recommendations Monitoring Quality of Care 2.1 Public and private purchasers, consumers, proviclers, practi- tioners, behavioral health care plans, anc3 accreditation organizations should continue to monitor anc3 assess the quality of care in the following ways: 2.1.1 Quality improvement should be a priority, anc3 principles and methods of improving quality should be acloptecl. 2.1.2 Accreclitation and review processes must be reliable and valid anc3 must be continuously reviewed anc3 improved. 2.1.3 Domains relevant to the effective treatment and preven- tion of behavioral health problems must be emphasized in accreditation processes. These include practitioner training, consumer education, im- provements in consumer self-care, anc3 the presence of a continuum of

SUMMARY 41 services, including wraparound services such as housing assistance, child care, anc3 transportation. 2.1.4 Accreditation processes must focus on areas of managed care in which there may be a risk of quality problems: (1) variability in utilization review; (2) inconsistent or inappropriate precertification pro' cesses; (3) vulnerable groups anc3 those who are unfamiliar with managed care processes; anc3 (4) conditions that occur frequently anc3 are treated by many practitioners, giving opportunities for variation in treatment prac- tices. 2.1.5 Performance measures must be relevant to treatment pro' cesses and outcomes. 2.1.6 Data must have demonstrable integrity. External, incle' penclent audits can help to validate data quality. 2.1.7 Stakeholcier consensus anc3 consumer satisfaction mea' sures must be incluciec3 in the tools used to monitor quality of care. 2.1.8 Outcomes measures should increasingly be based on evi- clence from research. Contracting 2.2 Quality of care should be clearly aciciressec3 in contracts between purchasers anc3 providers. 2.2.1 When plans contract or subcontract for the management anc3 delivery of behavioral health care services (e.g., health maintenance organizations contracting with carvec3-out managed behavioral health care firms), purchasers can benefit from inclepenclent audits of the contractor regarding the level of adherence to prespecifiec3 stanciarcis of performance with respect to quality. 2.2.2 Purchasers can benefit from carefully constructed contract language to ensure the quality, accessibility, anc3 effectiveness of behav' ioral health plans. Contracts should also specify the ways in which the quality anc3 effectiveness stanciarcis will be monitored anc3 enforced, in' clucling conditions for applying positive incentives for meeting or exceed' ing the stanciarcis anc3 penalties for substanciarc3 performance. Role of the Federal Government 2.3 The federal government should play a role in consumer protect Lion in managed care by:

42 MANAGING MANAGED CARE 2.3. ~ Promoting the improvement anc3 use of performance mea- sures for managed care. 2.3.2 Monitoring and studying the use and effectiveness of qual- ity assurance, accreditation, performance measures, anc3 outcomes mea surements. 2.3.3 Establishing minimum stanciarcis for accreditation organi- zations to achieve cleemec3 status (i.e., when the government, in its role as purchaser of managed care services, accepts accreditation as a measure of adequate quality anc3 consumer protection). Role of State Governments i, 2.4 The role of state governments in consumer protection should include the following: 2.4.! Support the development of consumer protection stan- ciarcis for managed behavioral health care by state mental health anc3 sub- stance abuse agencies, state Meclicaic3 agencies, state insurance ciepart- ments, state licensing boards, state hospitals, anc3 state child welfare agencies. State consumer groups, such as the chapters of the National Mental Health Association (NMHA), National Depressive anc3 Manic Depressive Association (NDMDA), National Association for Research on Schizophrenia anc3 Depression (NARSD), anc3 National Alliance for the Mentally 111 (NAMI), should be incluciec3 in the cievelopmentofstanciarcis. 2.4.2 Maintain the minimum necessary regulatory stanciarcis, nclucling the use of accreditation, to assure consumer protection while encouraging innovations in the delivery of care. 2.4.3 Consider offering cleemec3 status to specific accreditation organizations that meet state-ciefinec3 stanciarcis for quality of managed be- havioral health care services. Roles of All Levels of Government 2.5 Both federal and state governments shoulcl: 2.5.! Encourage the development of report carcis or other simi- lar materials to help inform consumers and families about specific plans anc3 the quality of care. 2.5.2 Include all stakeholciers (accreditation organizations, employers, state agencies, consumers, families, proviclers, and practitio- ners) in the clevelopment, implementation, and use of stanclarcls.

SUMMARY Provider Inclusion 43 2.6 Because managed care methods are increasingly applied to pub- lic systems, accreditation bodies anc3 managed care plans should evaluate the inclusion of a variety of types of practitioners, including substance abuse counselors anc3 mental health workers, in provider panels; collect information on practitioner effectiveness; anc3 remove any practitioners from networks only for performance reasons (e.g., poor outcomes and poor consumer satisfaction). 2.6.1 The Substance Abuse anc3 Mental Health Services Ac3- ministration (SAMHSA), Agency for Health Care Policy anc3 Research (AHCPR), Health Resources anc3 Services Administration (HRSA), anc3 National Institutes of Health (NIH) (National Institute on Alcohol Abuse anc3 Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], anc3 National Institute of Mental Health [NIMH]) should cosponsor re- search to evaluate the components of treatment that are most effective in providing behavioral health care, including strategies used by psychiatrists, psychologists, social workers, counselors, anc3 primary care practitioners. 2.6.2 The Substance Abuse anc3 Mental Health Services Ac3- ministration (SAMHSA), Agency for Health Care Policy anc3 Research (AHCPR), Health Resources anc3 Services Administration (HRSA), anc3 National Institutes of Health (NIH) (National Institute on Alcohol Abuse anc3 Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], anc3 National Institute of Mental Health [NIMH]) should cosponsor re- search to evaluate the cost-effectiveness of using different practitioner types to provide behavioral health care, including individual psychiatrists, psychologists, social workers, counselors, primary care practitioners, and teams with different practitioner combinations. 3. CONSUMER INVOLVEMENT Findings . Inclivicluals who have been treated for severe mental health prob- lems are most often referred to as "consumers," both by the inclivicluals themselves and by the organizations that represent them. · Consumers and families strongly desire to participate fully in cle- cision-making in treatment, setting behavioral health care stanciarcis, anc3 developing performance measures.

44 MANAGING MANAGED CARE Public behavioral health service systems make use of self-help groups, consumer-operatec3 services, anc3 experientially trained counselors (e.g., mental health workers anc3 substance abuse counselors) as service providers. These practices are both valuable anc3 highly valued in these systems because they help to support consumers ancl, for example, to assist with medication compliance. Quality measures are being clevelopec3 by organizations with vari- ous degrees of involvement by consumers anc3 consumer groups. Among consumers, the report card cievelopec3 by the Center for Mental Health Services (CMHS) is viewed as having the most consumer involvement. Recommendations 3.! Health care purchasers must be responsive to consumers anc3 families anc3 should develop means of ensuring their meaningful participa- tion in treatment decisions, measurement of satisfaction, anc3 measure- ment of treatment effectiveness. 3.2 Accreditation bodies should evaluate the extent of inclusion of consumers and families in treatment decisions and program planning. 3.3 The activities that are used to develop and review quality mea- sures should include all stakeholciers, including consumers, families, prac- titioners, anc3 researchers. 4. CULTURAL COMPETENCE Findings . appropriate care. Racial anc3 ethnic minorities frequently lack access to culturally In the effort to create smaller anc3 more efficient provider net- works, there is a risk of eliminating providers and groups who have special expertise with different cultures anc3 different healing practices (e.g., Afrocentric counseling anc3 Spanish-speaking services, sweat lodges for Native Americans, anc3 American Sign Language services for inclivicluals who are deaf). · Often, the reason given for exclusion of cultural practices is that accepted evidence of effectiveness floes not exist. The committee observes, however, that controlled trials or other outcomes assessments have not been clone for many, if not most, medical treatments.

SUMMARY Recommendations 45 4.! Health plans anc3 programs should be responsive to community demographics anc3 to the cultural needs of the populations that they serve. 4.2 Practitioners of alternative anc3 innovative treatments without an accepted research base should not arbitrarily be excluclec3 from health plans. If these treatments are used, their effectiveness should be stucliec3 so that stanciarcis of quality improvement can be cievelopec3. 4.3 Health plans should have an explicit mechanism for evaluating new anc3 innovative techniques anc3 types of practitioners. 5. SPECIAL POPULATIONS Findings · People with disabilities, such as inclivicluals who are deaf, hard of hearing, or blind, who use wheelchairs, or who have had traumatic brain injury, frequently lack access to care that is appropriate. Inclivicluals who have child care responsibilities, most of whom are women, often have barriers to participating in treatment. · Inclivicluals who have co~occurring substance abuse anc3 mental health problems need coorclinatec3 care to maintain their recovery. Recommendations 5.! Research is needled to identify incentives for plans to serve vul' nerable populations. The Substance Abuse anc3 Mental Health Services Administration (SAMHSA) should work with other federal agencies to develop a plan to conduct such research. 5.2 Plans that serve distinct populations should measure and evalu' ate the needs of those groups through reviews of research literature, con' sumer surveys, anc3 other appropriate mechanisms. 5.3 All plans should meet the same core stanciarcis. Supplemental stanciarcis can be cievelopec3 for special populations, whether they are in standalone programs or in mainstream plans, for example, for a child of an employed person with family coverage.

46 6. RESEARCH Findings MANAGING MANAGED CARE Health services research stimulates collaboration among provic3' ers, researchers, anc3 managed care organizations anc3 can facilitate the cle' velopment of valid anc3 useful measures of treatment processes anc3 out' comes through such collaborations. Research anc3 practice interact too infrequently, anc3 few incen' fives exist for collaboration among researchers, practitioners, anc3 policymakers. Outcomes research is often unresponsive to emerging problems in clinical practice anc3 also rarely provides direction for accreditation anc3 quality improvement efforts. The federal government plays a key role in the support of health services research anc3 thus in the development of the necessary knowledge base for improving the quality of behavioral health care. Recommendations 6. ~ The committee recommencis continued development of collabo' rative health services research in substance abuse anc3 mental health, anc3 encourages the Agency for Health Care Policy anc3 Research (AHCPR), Centers for Disease Control anc3 Prevention (CDC), Health Resources anc3 Services Administration (HRSA), National Institutes of Health (NIH) (National Institute on Alcohol Abuse anc3 Alcoholism [NIAAA], National Institute on Drug Abuse [NIDA], anc3 the National Institute of Mental Health ENIMH]), anc3 Substance Abuse anc3 Mental Health Ser' vices Administration (SAMHSA) to maintain, to evaluate, anc3, where necessary, to expand programs anc3 initiatives that support collaborative health services research. 6.2 The agencies mentioned above should support further research on the effectiveness of different treatment strategies for a variety of practi' tioner types anc3 for consumers with different needs. 6.3 Researchers should become more involved in studies carried out in managed care organizations and community~basecl settings and in other clinical outcomes research used to develop stanciarcis anc3 performance measures.

SUMMARY 7. WORKPLACE Findings environments. 47 Society anc3 incliviclual workers need safe anc3 supportive work The federal government has responclec3 through the passage of legislation (e.g., the Family anc3 Medical Leave Act anc3 the Americans with Disabilities Act) anc3 regulations concerning safety anc3 other stan- clarcls. · The workplace environment provides an excellent arena in which to aciciress behavioral health problems. Recommendations 7.! Employers should investigate the benefits of wellness activities, employee assistance programs, anc3 health risk reduction initiatives that enhance prevention, early intervention, access, anc3 treatment adherence for health anc3 behavioral health problems. 7.2 The Substance Abuse anc3 Mental Health Services Aciministra- tion (SAMHSA) should identify models of successful behavioral health programs in the workplace anc3 increase public awareness of these models. 8. WRAPAROUND SERVICES Findings · For long-term recovery to be sustained, the social aspects of con- sumers' lives must be aciciressec3 as part of the behavioral health care pro- viciec3. Medical anc3 managed care models often c30 not take these reha- bilitative and support services into account. In the substance abuse fielcl, these are known as wraparound services anc3 in the mental health field they are also known as enabling services. · Some symptoms of mental illness anc3 substance abuse such as severe anxiety anc3 depression, active psychosis, anc3 substance abuse with- cirawal interfere with social judgment anc3 functioning.

48 Recommendations MANAGING MANAGED CARE 8.1 Further research is neeciec3 to prioritize the essential components of a treatment regimen that can aciciress adequately the complex behav- ioral aspects of recovery from alcoholism anc3 other drug afflictions. 8.2 To maximize full functioning for inclivicluals with severe anc3 per- sistent mental illness, anc3 to optimize conditions supporting recovery for inclivicluals with chronic substance abuse problems, wraparound services such as social welfare, housing, vocational, anc3 rehabilitative services should be available anc3 should be coorclinatec3. 8.3 For children anc3 adolescents with severe emotional disturbances, educational anc3 home environment-family support services should be co- orclinatec3 anc3 integrated with mental health care. 8.4 Accreditation systems must aciciress the social anc3 rehabilitative aspects as well as the medical aspects of comprehensive treatment for ac3- cliction anc3 severe anc3 persistent mental illness. 9. CHILDREN AND ADOLESCENTS Findings · Services for children anc3 adolescents are fragmented across many different agencies, such as mental health, child abuse anc3 neglect, anc3 , Juven1 .e Justice. Many treatment models focus on a high-risk child or adolescent anc3 c30 not involve the family or other caretakers. Developmentally appropriate, comprehensive models for inter- vention anc3 treatment for adolescents are not well-ciefinec3 or applied in the current public anc3 private systems. The needs of many high-risk youth are unmet because traditional systems c30 not focus on this population. · Prevention and treatment programs for mental health and sub- stance abuse problems are not adequately linked. Recommendations 9.! The Substance Abuse anc3 Mental Health Services Aciministra- tion (SAMHSA), National Institutes of Health (NTH) (National Insti- tute on Alcoholism anc3 Alcohol Abuse ENIAAA], National Institute on Drug Abuse ENIDA], and National Institute of Mental Health ENIMH]),

SUMMARY 49 anc3 the Health Research anc3 Services Administration (HRSA) should identify exemplary models of coorclinatec3 systems of care for children anc3 adolescents. 9.2 The Substance Abuse anc3 Mental Health Services Aciministra- tion (SAMHSA), National Institutes of Health (NIH) (National Insti- tute on Alcoholism anc3 Alcohol Abuse ENIAAA], National Institute on Drug Abuse ENIDA], anc3 National Institute of Mental Health ENIMH]), anc3 the Health Research anc3 Services Administration (HRSA) should identify exemplary models of linking behavioral health treatment anc3 pre- vention programs for children anc3 adolescents to aciciress suicide, substance abuse, and other areas. 9.3 The Substance Abuse anc3 Mental Health Services Aciministra- tion (SAMHSA), National Institutes of Health (NTH) (National Insti- tute on Alcoholism anc3 Alcohol Abuse ENIAAA], National Institute on Drug Abuse ENIDA], and National Institute of Mental Health ENIMH]), and the Health Research and Services Aclministration (HRSA) should support research to identify the elements of developmentally appropriate treatment that should be available to adolescents who are abusing alcohol or drugs or who have mental health problems. 9.4 The public anc3 private systems must make efforts to develop ser- vice capabilities to meet the needs of adolescents who are abusing alcohol or drugs anc3 adolescents who have mental health problems. 10. CLINICAL PRACTICE GUIDELINES i, Findings · Practice guidelines are clevelopec3 by professional organizations, managed care organizations, anc3 other groups. The development of guicie- lines is not always systematic, anc3 guidelines are not always linked to em- pirical findings. Little or no information is available on successful strategies for mplementing guidelines. · Accreclitation tends to measure whether plans or managed care organizations have guidelines in place anc3 floes not aciciress the quality of the guidelines used by plans or organizations, or the extent to which care is actually monitored anc3 changed according to those guidelines.

so Recommendations MANAGING MANAGED CARE 10.1 The development of clinical practice guidelines should be linked to outcomes research, performance standards, and accreditation. 10.2 The Agency for Health Care Policy and Research (AHCPR), Substance Abuse and Mental Health Services Administration (SAMHSA), and other agencies and organizations that develop guide- lines should sponsor additional research that examines the successful implementation of guidelines and identifies successful implementation models. 10.3 Practitioners and consumers should be included in the develop- ment of practice guidelines. 11. PRIMARY CARE Findings . Many individuals (10 to 20 percent of the population) consult primary care physicians for behavioral health problems. · Responsibility for behavioral health care is frequently divided between primary and specialty settings, which are not well integrated, and this division of responsibility results in poor coordination of care. care . Few guidelines exist for behavioral health treatment in primary Some individuals may be treated more successfully in specialty settings than in primary care settings. Recommendations 11.1 This committee endorses the view of the Institute of Medicine (IOM) Committee on the Future of Primary Care, which recommended "the reduction of financial and organizational disincentives for the ex- panded role of primary care in the provision of mental health services" and "the development and evaluation of collaborative care models that integrate primary care and mental health services more effectively. These models should involve both primary care clinicians and mental health pro- fessionals" ~ IOM, 1 996a, p. 13 7 ). 11.2 This committee recommends that the above recommendation include alcohol and other drug abuse problems as a defined area of exper- tise.

SUMMARY 12. ETHICAL CONCERNS Findings . 51 The field of health care ethics embodies ethical principles that address risks in the areas of autonomy, access, informed consent, practitio- ner-patient relationships, and confidentiality. Ethical challenges and problems exist in both the traditional fee- for-service system and in the rapidly developing managed care system, al- though the incentives, risks, and oversight strategies differ in the two set- tings. Cultural competence and sensitivity are ethical issues. Recommendations 12.1 Managed care organizations should be able to demonstrate that they recognize and have concern for the ethical risks created by managed care systems. Additionally, they should substantiate the use of safeguards that protect and maintain ethical standards and practices. These would include the following: . cures. . cedures. . a clear description of a plan, its benefits, and grievance proce accessible and responsive grievance, complaint, and appeals pro effective strategies to maintain confidentiality while meeting the needs of practitioners to coordinate care, . i, n the network, resolution, . culturally appropriate and gender-specific service practitioners consumer surveys and measures of consumer satisfaction, consumer representation on policy development and grievance continuous improvement protocols to promote better outcomes, and · no contractual or other limitations for physicians and other prac- titioners concerning the discussion of clinically appropriate treatment op- tions with patients and families. 12.2 A careful review of ethical issues in various settings, for example,

52 MANAGING MANAGED CARE managed care organizations, networks, anc3 fee~for~service settings, is neeciec3. The Substance Abuse anc3 Mental Health Services Aciministra' tion (SAMHSA), Health Care Financing Agency (HCFA), and Agency for Health Care Policy anc3 Research (AHCPR) shouic3 develop a plan to examine ethical issues. CONCLUDING OBSERVATIONS In developing these recommendations, the committee was mincifu! of the rapid rate of change in the health care system anc3 the need to antic)' pate new directions anc3 trencis. This report is therefore intenciec3 to pro' vine a general, overarching framework that shows how all of the varied current anc3 fixture quality improvement activities can relate, anc3 that also may support creative anc3 collaborative initiatives to improve the quality of care. The committee's intention is that each recommendation might be implemented in a variety of ways, clepencling on the concerns anc3 capacity of the state or local agencies, managed care organizations, community' based treatment groups, consumer groups, professional associations, or other groups that are considering these issues. The committee agreed that all of the stakehoIclers consumers, prac' titioners, public anc3 private purchasers, managed care companies, accredit ration organizations, and other citizens and groups with a stake in the qual' ity of care can anc3 shouic3 work together to reach a coorclinatec3, collaborative, anc3 consensus~basec3 approach to quality measurement anc3 treatment. Efforts to achieve consensus, both on definitions anc3 measures of quality, are a good investment in the effort to provide the highest- quality care at the lowest appropriate price. REFERENCES EAPA (Employee Assistance Protessionals Association, Inc.). 1995. Glossary of Employee Assis- tance Terminology. Arlington, VA: Employee Assistance Professionals Association, Inc. EBRI (Employee Benefit Research Institute). 1996. EBRI Issue Brief. February. England MJ, Vaccaro VA. 1991. New systems to manage mental health care. Health Affairs 10(4): 129-137. GHAA (Group Health Association of America). 1996. 1995 National Directory of HMOs. Washing- ton, DC: Group Health Association of America. HIAA (Health Insurance Association of America). 1996. Sourcebook of Health Insurance Data, 1995. Washington, DC: Health Insurance Association of America. Iglehart JK. 1996. Health policy report: Managed care and mental health. The New England Journal of Medicine 334(2):131-135. IOM (Institute of Medicine). 1989. Controlling Costs and Changing Patient Care? The Role of Utilization Management. Washington, DC: National Academy Press.

SUMMARY 53 IOM. 1990a. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press. IOM. 1990b. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: Na- tional Academy Press. IOM. 1990c. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press. IOM. 1990d. Treating Drug Problems. Vol. 1. Washington, DC: National Academy Press. IOM. 1993. Employment and Health Benefits: A Connection at Risk. Washington, DC: National Academy Press. IOM. 1996a. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press. IOM. 1996b. Pathways of Addiction: Opportunities in Drug Abuse Research. Washington, DC: National Academy Press. JCAHO (Joint Commission on Accreditation of Healthcare Organizations). 1996. Comprehensive Accreditation Manualfor Health Care Networks. Chicago, IL: Joint Commission on Accredita- tion of Healthcare Organizations. Kessler RC, McGonagle KA, Zhao S. Nelson CB, Hughes M, et al. 1994. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psy- chiatry 51:8-19. Mechanic D, Schlesinger M, McAlpine DD. 1995. Management of mental health and substance abuse services: State of the art and early results. The Milbank Quarterly 73(1):19-55. Miller RH, Luft HS. 1994. Managed care plan performance since 1980: A literature analysis. Journal of the American Medical Association 271(19):1512-1519. NCQA (National Committee for Quality Assurance). 1995. Standards for Accreditation, 1995 Edi- tion. Washington, DC: National Committee for Quality Assurance. Open Minds. 1996. Managed Behavioral Health Market Share in the United States, 1996-1997. Gettysburg, PA: Open Minds. SAIC (Science Applications International Corporation). 1995. A Comparison of JCAHO and NCQA Quality Oversight Programs. National Quality Monitoring Project, Task lb, Submitted to the Office of the Assistant Secretary of Defense, Health Affairs. Beaverton, OR: Science Applica- tions International Corporation. SAMHSA (Substance Abuse and Mental Health Services Administration). 1995. Substance Abuse and Mental Health Statistics Sourcebook. Publication No. (SMA) 95-3064. Washington, DC: U.S. Government Printing Office. Shore ME, Beigel A. 1996. The challenges posed by managed behavioral health care. The New England Journal of Medicine 339(2): 116-118. Slaven T. 1996. Personal communication to the Committee on Quality Assurance and Accreditation Guidelines for Managed Behavioral Health Care. Rehabilitation Accreditation Commission. May. Stair T. 1996. Personal communication to the Institute of Medicine. Open Minds. October. United HealthCare Corporation. 1994. The Managed Care Resource: The Language of Managed Health Care and Organized Health Care Systems. Minnetonka, MN: United HealthCare Cor- poration.