Managing Managed Care Quality Improvement in Behavioral Health (1997) / Chapter Skim
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INTRODUCTION
INTRODUCTION
Pages 15-39
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From page 15... ...
, point~oEservice plans, and other forms of managed care networks, such as managed behavioral health care organizations, differ in their organizational structures, types of practitioners and services, access strategies, payment for practitioners, and other features. Their goals, however, are similar: to control costs through improved efficiency and coordination, to reduce unnecessary or inappro' priate utilization, to increase access to preventive care, and to maintain or improve the quality of care (IOM, 1996a; Miller and Luft, 1994~.
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. physical health, and for mental health and substance abuse care there also have been few alternatives to hospitalization.
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News arid World Report, and Newsweek and in national newspapers including The Wall Street.Toumal, The New York Times, and USA Today. Report cards and ratings are produced by managed care organizations, governments, purchaser coalitions, and trade organizations,
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to convene a committee to ex' amine quality assurance and accreditation guidelines for managed behavioral health care. The committee's charge was to provide a framework to guide the development, use, and evaluation of performance indicators, accreditation stan' cards, and quality improvement mechanisms in managed behavioral health care (i.e., services related to mental health, alcohol abuse, and drug abuse)
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John Bartlett American Managed Behavioral Healthcare Association Public Workshop, April 18, 1996, Washington, DC Six themes emerged from the committee's review of the research and incus' try literature. The themes were echoed and amplified in the testimony from indi' viduals from the managed behavioral health care industry, accreditation organ)
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This same set of circum' stances could occur in both fee~for~service and managed care settings, although the next steps for reviewing the treatment decisions might be very different. Despite such challenges, the committee believes that all of the stakeholders consumers, practitioners, public and private purchasers, managed care com' panics, accreditation organizations, and other citizens and groups with a stake in the quality of care can and must work together to reach a coordinated, collabo' rative, and consensus approach to quality measurement and treatment.
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3. Differences in the structure of insurance coverage for behavioral health care compared with that for physical health care, including the continued appli' cation of lifetime and annual limits and other restrictions, have drawn the atten' tion of state and federal lawmakers, businesses, lobbies, and advocacy groups that seek parity for behavioral and physical health care coverage.
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From page 22... ...
, the application of managed care principles means that practitioners begin to share clinical decisionmaking with payers, insurance plan managers, as well as with consumers, and 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 individual is receiving care from a clinician, but used the term consumer more broadly to refer to individuals in most circumstances, including individuals who are making purchasing decisions, who are evaluating report cards, or who have already had treatment and are in recovery.
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, and their estimated costs to society are far greater than the costs of treatment (see Chapter 3, Challenges in Delivery of Behavioral Health Care)
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has recently released a consumer-oriented report card for mental health services in a collaborative effort with many consumers and consumer groups (CMHS, 1996~. Advocates are far better organized and influential in the mental health field than in the substance abuse field, where stigma and the fear of prosecution for using illegal substances are powerful deterrents to the open discussion of issues related to quality of care and where traditions of anonymity inhibit advocacy.
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PRACTITIONERS The variety of practitioners in the behavioral health care system adds com' plexity. In the behavioral health care system, the professional specialty practitioners include psychiatrists, clinical psychologists, psychiatric nurses, social work' ers, marriage and family therapists, and substance abuse counselors.
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Ann Froio ComCare Public Workshop, May 17, 1996, Irvine, CA With managed care, treatment decisions are not only based on the private de' cisions of practitioners, clients or patients, and the clients' or patients' families. Managed behavioral health care companies in some cases approve a practitioner's treatment plans, so practitioners must disclose confidential information.
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From page 27... ...
The variations in practice, however, would seem to warrant standardization on the basis of evidence of treatment electiveness. In the vivid words of one commentator, behavioral health clinicians are sharply divided about whether "to wage a scorched-earth, take-no-survivors holy war against the 'great Satan' of managed care or to pursue a quality improvement strategy of making managed care better" (Sabin, 1995, p.
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Expenditures for mental health and substance abuse treatment account for approximately 10 percent of all health care spending (Frank and McGuire, 1996~. Although an estimated half of all individuals who have behavioral health problems do not receive care (see Table 1.3 I, the growth of spending for mental health and substance abuse treatment has been a matter of considerable concern to both private payers and state govemments.
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In the committee's view, many new developments in these areas, such as the CMHS consumer~oriented report card, the American Managed Behavioral Healthcare Association's (AMBHA's) Performance Measures for Managed Be' havioral Healthcare Programs, and state~level initiatives such as the Consumer Quality Review Teams used in Georgia, Pennsylvania, and Ohio, are likely to begin to be incorporated into contracts.
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Managed care plans use a network of selected providers, which includes hospitals, residential programs, and practitioners. Managed care organ)
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The mid-1980s also saw the emergence of a number of managed behavioral health care companies that offered to reduce the spiraling costs of behavioral health care (England and Vaccaro, 1991~. A fur ther discussion of these trends in the health care industry is presented in Chapter 2.
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These accreditation entities address organizational capacity, internal management and quality improvement processes, and related issues. In general, accreditation standards are evolving, and the standards for individual practitioners are better developed than the relatively new standards for managed care plans.
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The committee also sought other empirical findings to inform the committee's deliberations, including current activities and surveys in the managed behavioral health care industry, such as those performed by AMBHA and the Institute for Behavioral Healthcare, as well as documents and reports from federal agencies such as the Center for Substance Abuse Treatment, and CMHS, NIMH, the National Institute on Drug Abuse, National Institute on Alcohol Abuse and Alcoholism, and HCFA. The committee also reviewed descriptions of five accreditation organizations: CARE, COA, ICAHO, NCQA, and URAC.
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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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4. The expense of successful and appropriate treatment for mental health and substance abuse problems can be a barrier and a burden, putting individuals and families at substantial financial risk.
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ORGANIZATION OF THE REPORT This report has been written for a broad audience, including the stakeholders who are concerned about quality: public and private purchasers, consumers and families, the managed care industry, professional organizations, accreditation organizations, practitioners in primary care and specialty sectors, and policymakers. Health care quality is complex, and it is addressed in numerous ways: accreditation; quality assurance programs; licensure, certification, and other credentialing activities; clinical practice guidelines; consumer satisfaction; report cards; and other means.
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Chapter 7, Outcomes, reviews what is known from research about treatment outcomes. This chapter is supplemented by two pa' pets in Appendixes B and C: Thomas McLellan and colleagues address questions of substance abuse outcomes research, and Donald Steinwachs discusses outcomes re' search in mental health.
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From page 38... ...
1995. Management of mental health and substance abuse services State of the art and early results.
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From page 39... ...
1995. Substance Abuse and Mental Health Statistics Sourcebook.
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Key Terms
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