Managing Managed Care Quality Improvement in Behavioral Health (1997) / Chapter Skim
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Pages 184-225
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From page 184... ...
. This chapter begins with a general discussion of quality and accountability in the private sector, an overview of methods of quality improvement, and a com' parison of current quality improvement methods in managed behavioral health care.
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From page 185... ...
Consumers and providers who believe that autonomous health resource decisions on the basis of tradition and the health care contract are consequently in conflict with such policies. The tensions over cost controls have increasingly focused concerns about cost~containment efforts on qual' ity issues such as the following: · qualifications of and consumers' geographic access to a comprehensive range of providers; · prevention of avoidable illness and provision of timely and focused treatment interventions; availability of services, on the basis of urgency of need; courtesy, convenience, and comfort of services; compassion and kindness of care; competence of providers to institute most appropriate evaluations and treatments, which would result in services that would result in the least risk to the patient and with the best health status outcome; and · administrative efficiencies of health care services that promote quality through eEective communications, consumer and provider education, decision support, and quality management, treatment coordination, and other systems.
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From page 186... ...
In addition, many managed behavioral health care organizations have developed "certification" methods based on various quality parameters and sources to establish the qualifications of various institutional and professional providers that are contracted into their networks. Managed care accreditation has become increasingly popular for public- and private-sector health programs because it is viewed as the best current system for creating accountability and quality, even though there is limited evidence to support the relationship between adherence to quality standards and improvements in patients' health status.
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From page 187... ...
The complexities and multiple requirements imposed on providers to account to many agencies and managed care organizations and managed behavioral health care organizations has caused credentialing-privileging to become a costly and time-consuming enterprise for both organizations and individual practitioners. The evolution of integrated credentialing systems could substantially reduce these burdens and maintain protection for the public.
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From page 188... ...
Of any single institution, these consulting firms have collectively had one of the most profound and least publicized impacts on managed care. Their influence over the managed care purchasing decisions of health plans, through the promotion of their performance requirements, selection of managed care organization and man' aged behavioral health care organization vendors, and auditing of managed care operations, has been a major contributor to the development of monitoring stan' cards and systems embraced by other organizations (e.g., American Managed Be' havioral Healthcare Association [AMBHA]
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From page 189... ...
Significant resources are being allocated to refine specific methods of assessing quality through consumer evaluation and to systematically seek customers' opinions in designing clinical services and improving the quality of clinical services. National and local newspapers and magazines provide consumers with information by comparing different health plans, including the results of consumer satisfaction surveys and other data available from report cards.
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From page 190... ...
In less than 10 years this phenomenon grew to the point that now more than 120 million people with insured or entitled behavioral health care benefits receive care in one of these managed care arrangements (HIAA, 1996~. Employers as Purchasers of Behavioral Health Care Managed behavioral health care organizations have encouraged the documentation of efforts to account for quality of care and services.
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From page 191... ...
The Foundation for Accountability (FACCT) , representing a broad coalition of public and private purchasers and others, has begun to develop and test tools that will allow documentation of population-specific functioning, quality of life, satisfaction with services, and risk reduction for a number of medical conditions commonly seen in health plans, such as diabetes, asthma, breast cancer, coronary artery disease, and low back pain (FACCT, 1995~.
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From page 198... ...
The evolu' tion of other potentially large systems, such as the Joint Commission on Accredi' ration of Healthcare Organizations (ICAHO) , NCQA, Utilization Review Accreditation Commission (URAC)
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From page 199... ...
Over time it is probable that a best practices system will emerge that monitors, measures, and reports on the relevant information needed to determine electiveness in sensitive, reliable, specific, and valid terms. The process of developing best practices will be facilitated if purchasers and managed care organizations include a variety of stakeholders in the discussions, including practitioners, administrators, researchers, accreditation organizations, public agencies, and the general public.
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From page 200... ...
One study is being conducted by the National Research Council at the request of the Office of the Assistant Secretary for Health, to examine the technical issues involved in adopting performance measures in mental health and substance abuse, as well as other areas (human immunodeficiency virus infection, sexually transmitted diseases, tuberculosis, chronic disease, immunization, prevention of disabilities among children, rape prevention, and emergency medical services)
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From page 201... ...
SAMHSA also provides technical assistance to states and local providers conceming managed behavioral health care systems, including the development of performance-monitoring systems that include consumers and families, and the negotiation and management of contracts with managed behavioral health care organizations. Mental Health Statistics Improvement Program Public mental health programs have recently experienced several transformations concurrently with the development of managed behavioral health care systems.
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From page 202... ...
In addition, HCFA has worked with NCQA to develop HEDIS 3.0 and by 1997 will require health plans serving the Medicare population to use some of the HEDIS measures. HCFA also is working with FACCT to develop outcome measures for plan performance.
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From page 203... ...
The majority of AHCPR's activities are aimed at improving the quality of health care. Accordingly, the agency works with several organizations, including the Foundation for Accountability, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, and the American Medical Association, to help to provide a science base for quality measurement, and to assist in translating research findings to quality measures.
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From page 204... ...
The domains of the vari' ous accreditation agencies are different but sometimes overlap. Accreditation Organizations The committee reviewed accreditation materials from five organizations that accredit behavioral health plans, programs, and services: CARF, COA, ICAHO, NCQA, and URAC.
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From page 205... ...
National Committee for Quality Assurance (NCQA) NCQA was formed in 1979 by two managed care associations, the Group Health Association of America and the American Managed Care and Review Association (now merged and renamed the American Association of Health Plans)
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From page 206... ...
Systematic information collection Reviews of fiscal management 8. Reviews for sufficient resource allocation Emphasis on CQI and outcomes evaluation To define expectations regarding the high quality of management and service delivery Behavioral health-specific standards and standards for community-based, therapeutic providers 1.
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From page 207... ...
To provide information that enables purchasers and consumers to distinguish plans on the basis of quality New behavioral health standards for carve-out companies and HMOs with behavioral health services carved in. Measures on substance abuse, depression, use of medications, and family visits, are being evaluated for inclusion in future reporting sets.
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From page 208... ...
208 MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH TABLE 6.2 Continued Features CARE COA JCAHO Approach to utilization No identifiable UM section, Utilization management but similar areas covered addressed under specific elsewhere are standards: 1. Accessibility review of 1.
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From page 209... ...
Site visits capabilities in documentation requirements Confidentiality of patientspecific information obtained during utilization management process 2. Scope of responsibility for accreditation 3.
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From page 210... ...
210 MANAGING MANAGED CARE: QUALITYIMPROVEMENTIN BEHAVIORAL HEALTH TABLE 6.2 Continued Features CARE COA IDAHO Rights Defines areas of rights to protect and promote consumer rights: 1. Consumer participation in treatment planning 2.
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From page 211... ...
Education standards to promote patient/family education to improve health status Defines areas and measurement of member rights and responsibilities: 1. To participate in treatment planning 2.
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From page 212... ...
Day treatments 18. Therapeutic wilderness programs NOTE: CD, chemical dependency; CQI, continuous quality improvement; HMO, health maintenance organization; IPA, independent practice association; MBHO, managed behavioral health organization; MCO, managed care organization; MR/DD, mentally retarded and developmentally disabled; PHO, physi' clan hospital organization; POS, point of service plan; PPO, preferred provider organization; QI, quality improvement; UM, utilization management; and UR, utilization review, SOURCES: CARF (1996)
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From page 213... ...
Although HEDIS data collection is not required for NCQA accreditation, managed care organizations regularly institute HEDIS measures. Utilization Review Accreditation Commission URAC was formed in 1990 after a series of meetings with the American Managed Care and Review Association and utilization review industry represen
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From page 214... ...
Changing Environment of Accreditation There has been a proliferation and growth of accreditation organizations to match the structural changes in the industry. As described above, new accredited tion organizations form to review any structure devised in managed care.
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From page 215... ...
The Accreditation Process The accreditation process entails generating standards and then comparing the actual delivery of care with the standards. There are at least seven distinct steps: 1.
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From page 216... ...
Unless the accreditation process incorporates principles of quality in estate' fishing standards and the survey process, there is a danger of inconsistency, vari' ance, and unreliability. There are many opportunities in the accreditation process for variance in measures, interpretations, and dispositions, leading to disparate outcomes.
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From page 217... ...
The benefits for the substance abuse and mental health care and services provided within a plan are limited. Individuals with such problems often require more than the benefits over, and turn to publicly~funded programs for additional care.
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From page 218... ...
States also are beginning to review and update traditional regulatory and contracting practices and to develop arrangements for deemed status. For example, COA holds deemed status in 22 states that recognize the COA accreditation process in lieu of Medicaid certification, state monitoring, or licensing (COA, 1996c)
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From page 219... ...
This would create an incentive for health plans and other organizations to develop quality measures and for accreditation organizations to measure a range of domains that extend beyond what any subset of interest groups might propose. Achieving deemed status could also require that measurements be uniformly defined and collected by third parties.
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220 CD o o so CD o o U)
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REFERENCES AMBHA (American Managed Behavioral Healthcare Association, Quality Improvement and Clinical Services Committee)
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From page 224... ...
Oakhrook Terrace, IL Joint Commission on Accreditation of Healthcare Organizations.
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From page 225... ...
1996b. Accreditation Standards For Managed Behavioral Healthcare Organizations.
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