Managing Managed Care Quality Improvement in Behavioral Health: Summary (1997) / Chapter Skim
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Behavioral health problems are common: every year, an estimated 52 million Americans have some kind of mental health or substance abuse problem (see Table ~ )
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have turned to managed behavioral health care companies to control costs anc3 improve quality anc3 access for mental health anc3 substance abuse care. Traclitionally, 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 alternatives to hospitalization.
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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)
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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 effectiveness of different managed care options.
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Impact may vary depending on the level of responsibility for quality of care within an organization, the regulatory mechanisms that apply, the nature and extent of the relevant outcomes research base, and other factors.
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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)
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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.
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, the Joint Commission on Accreditation of Healthcare Organizations (ICAHO) , the National Committee for Quality Assurance (NCQA)
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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.
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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.
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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 interrelatec3, significant, anc3 complex changes that are uncier way anc3 the vulnerability of inclivicluals who suffer from serious mental illness anc3 aciclictions 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.
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Chapter 7, Outcomes, reviews what is known from research about treatment outcomes. This chapter 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
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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.
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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.
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Purchaser: a group such as an employer, unit of government, association, or coalition that negotiates for and buys health care on behalf of a specified group, generally to cover specific benefits and services at reduced prices. Stakeholders: individuals and groups for whom the cost, availability, accessibility, or quality of care hold direct implications, including individuals who receive care and their families, practitioners, public and private purchasers, managed care companies, accreditation organizations, and policy makers.
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, 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 included in the category "Insured population" to illustrate their relative proportions.
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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.
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19 ho Ct ~do Ct , CtCtCt U)
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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
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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.
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and other managed behavioral health care service organizations began in the private sector, but are beginning to develop contracts with public mental health anc3 substance abuse agencies.
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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 alcoholism, 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.
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Gwen Rubinstein Lega/Action Center Public Workshop, April is, 1996, Washington, DC However, direct and insufficiently planned applications of privatesector 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 exclude social and support services and, because they emphasize acute care, tend to have little experience in the management of chronic and disabling conditions.
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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.
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The nature of managed care anc3 the nature of mental illness anc3 substance abuse combine to make access a crucial issue. Well-clevelopec3 public anc3 private health care anc3 behavioral health care plans will promote access to mental health anc3 substance abuse services.
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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 collect anc3 publicly report information on their performance.
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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.
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COA was founded in 1977 and currently accredits about 1,000 behavioral health programs anc3 3,000 social service programs in the United States and Canacla. COA has developed standards for more than 50 services, including outpatient mental health anc3 substance abuse services, clay treatment, foster care anc3 clay care for children, services for people
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In the 1970s, ICAH began to develop aciclitional accreditation programs for psychiatric facilities, substance abuse programs, community mental health programs, anc3 ambulatory care facilities. In 1987 the name was changed to ICAHO to reflect the new activities anc3 to anticipate a new activity, accreditation of managed care organizations (SAlC, 19951.
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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)
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Utilization Review Accreditation Commission (URAC) URAC was formed in ~ 990 after a series of meetings with the American Managed Care anc3 Review Association anc3 utilization review inclustry representatives inclicatec3 that there was a need for stanciarcis for utilization review anc3 an inciepencient accreditation organization.
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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)
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~ 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 treatment is complex.
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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.
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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.
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· The fundamental problems in mental health anc3 substance abuse care cannot be fully aciciressec3 without changing the structure anc3 financing of the system anc3 attending to the problem of the separate public anc3 private sectors of care. Recommendations i.!
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all play roles in accrediting managed care plans that cover mental health anc3 substance abuse care. The American Managed Behavioral Healthcare Association (AMBHA)
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. Quality improvement methods have great potential but are still in preliminary stages for mental health anc3 substance abuse services.
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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.
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Support the development of consumer protection stanciarcis for managed behavioral health care by state mental health anc3 substance abuse agencies, state Meclicaic3 agencies, state insurance ciepartments, state licensing boards, state hospitals, anc3 state child welfare agencies. State consumer groups, such as the chapters of the National Mental Health Association (NMHA)
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2.6.2 The Substance Abuse anc3 Mental Health Services Ac3ministration (SAMHSA) , Agency for Health Care Policy anc3 Research (AHCPR)
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appropriate care. Racial anc3 ethnic minorities frequently lack access to culturally In the effort to create smaller anc3 more efficient provider networks, 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)
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The Substance Abuse anc3 Mental Health Services Administration (SAMHSA) should work with other federal agencies to develop a plan to conduct such research.
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~ 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)
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Medical anc3 managed care models often c30 not take these rehabilitative 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.
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Recommendations 9.! The Substance Abuse anc3 Mental Health Services Aciministration (SAMHSA)
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should identify exemplary models of linking behavioral health treatment anc3 prevention programs for children anc3 adolescents to aciciress suicide, substance abuse, and other areas. 9.3 The Substance Abuse anc3 Mental Health Services Aciministration (SAMHSA)
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, Substance Abuse and Mental Health Services Administration (SAMHSA) , and other agencies and organizations that develop guidelines should sponsor additional research that examines the successful implementation of guidelines and identifies successful implementation models.
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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.
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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.
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1995. Management of mental health and substance abuse services: State of the art and early results.
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