Managing Managed Care Quality Improvement in Behavioral Health (1997) / Chapter Skim
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TRENDS IN MANAGED CARE
TRENDS IN MANAGED CARE
Pages 40-75
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From page 40... ...
The introduction and expansion of managed care strategies have altered the organization of general health care (e.g., Shortell et al., 1994) and have begun to influence the delivery of privately and publicly reimbursed mental health and substance abuse treatment.
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From page 41... ...
the role of purchasers in managing costs, and (4) the rec' ognition of quality assurance and quality improvement mechanisms as tools for purchasers in making informed decisions.
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From page 42... ...
Currently, the feature most associated with managed care is cost containment. Compared with indemnity plans, managed care plans have significantly lower rates of utilization of inpatient hospitalization, lower rates of utilization of more expensive and discretionary tests, increased utilization of preventive services, and mixed results on quality as measured through outcomes (Miller and
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From page 45... ...
. Increasingly, advocates look to managed behavioral health care to improve the quality of care for individuals with behavioral health problems, and because increasing numbers of public-sector clients are being enrolled in carve-outs, quality improvement is a high priority.
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From page 46... ...
Report cards and public reporting of responses to patient satisfaction surveys provide opportunities for employers and employees to choose among competing health plans by comparing the relative value offered by various plans. The result of the combination of aggressive buying by employers and the use of competition has been a dramatic shift in enrollment patterns across plan types.
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From page 47... ...
One way to achieve the savings is through capitated health plans. As of June 1995, about 32 percent of Medicaid program beneficiaries were enrolled in capitated managed health care plans (HCFA, 1996~.
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From page 48... ...
Frank and colleagues (1995) have examined public and private contracts for managed behavioral health care, and they suggest that purchasers may achieve a balance between cost control and access through the use of "soft" capitation, which shares risks between the purchaser and managed care organization, thereby reducing the potential profit and losses for the managed care organization.
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From page 49... ...
One way to assist in coordination is to include in contracts requirements for linkages to support wraparound services such as transportation and child care (Institute for Health Policy, 1995~. BEHAVIORAL HEALTH IN THE NEW MARKETPLACE As employers and states have moved in the direction of contracting with managed care organizations to care for at-risk individuals, providers, consumers, and policymakers have become concerned about the consequences of these developments with regard to access to care and the quality of treatment for individuals suffering from mental health and substance abuse problems.
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From page 50... ...
In the substance abuse area, managed behavioral health care plans result in dramatic reductions in the use of 28-day inpatient programs and the expanded use of residential treatment programs. Many of the criticisms of the new organizational and financial arrangements associated with managed behavioral health care stem from their efforts to respond to certain problems inherent in trying to insure health care.
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From page 51... ...
It is therefore possible that individuals with behavioral health problems and family members who act on their behalf will be more likely to foresee their use of health care services than other individuals. For this reason health plans that offer generous coverage and high-quality behavioral health care services or that allow relatively free access to services will disproportionately attract users of behavioral health services to their plans.
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From page 52... ...
In Medicaid programs and private insurance plans, choices about how to or' ganize the purchase of behavioral health services are quite similar. In comparison, public mental health and substance abuse systems typically face more complexity with respect to moral hazard because these systems serve as the provider of last resort in the United States.
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From page 53... ...
Digital Equipment Corporation's (1995) standards for behavioral health care require quality improvement plans, requirements for staEing levels and stab credentials, and access to case management to support the treatment interventions.
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From page 54... ...
Pressure to develop internal quality improvement activities may paradoxically be a positive result of external accreditation approaches. States regulate health care practice by licensing individual practitioners, for example, physicians, nurses, psychologists, and social workers (see Table 4.1~.
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From page 55... ...
care, cert~r~cat~on or contract/plan A spectrtcattons Standards for providers, not plans Variable patterns May duplicate accreditation Cover care other than medical care State Professional Licensure Standards Counselors Nurses Physicians Psychologists Social workers Outcomes Consumer Satisfaction Internal, e.g., surveys External, e.g., Ohio Consumer Quality Review Team Outcomes Measures MHSIP Highly relevant to consumers in public sector Covers wide range of issues, including quality of life and care other than medical care Being field tested NAMI roundtable Pilot testing under way Focuses on feasibility of collecting outcome data from individuals with depression and schizophrenia System Performance Standards AMBHA/PERMSa Sums process measures Wide database Focuses on medical/ clinical issues aPERMS, Performance-Based Measures For Managed Behavioral Healthcare Programs.
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From page 56... ...
, and thus does not require screening and early intervention for substance abuse and mental health problems (Digital Equipment Corporation, 1995~. In planning for this cavitation, the managed care organizations were really convinced that they wanted to, they had the responsibility to, and to a great degree were motivated to keep these patients well and out of the hospital.
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From page 57... ...
. Although the managed care plans may urge minimal state regulation to minimize their costs and maximize creative treatment planning, consumers may be less protected because standards of care have not been established for many emerging treatment techniques.
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From page 58... ...
The development of credentialing standards was an early priority for the field and, with support from the National Institute on Alcohol Abuse and Alcoholism, trade groups collaborated and proposed 12 core competency areas and credentialing guidelines (Birch and Davis Associates, Inc., 1984~. A review of state procedures for the certification of substance abuse counselors found that all states support certification, but in most states the certification is voluntary and coordinated through an independent nongovernmental entity, usually a trade group organization (Health Management Resources, Inc., and Birch and Davis Associates, Inc., 1992~.
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From page 59... ...
Linda Kaplan National Association of Alcohol and Drug Abuse Counselors Public Workshop, April 18, 1996, Washington, DC Loss of Current Providers Public~sector service systems often appear to be a patchwork of service agen' cies that specialize in the unique and complex needs found among uninsured indi' viduals and individuals with public insurance. The service providers may include state and county hospitals and clinics, as well as private nonprofit agencies such as community~based programs staked with licensed, certified, and noncertified coun' selors.
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From page 60... ...
Guidelines developed by a consulting firm, Milliman and Robertson, Inc., are used by health plans at Prudential, Cigna, U.S. Healthcare, Kaiser Permanente, and many Blue Cross and Blue Shield affiliates, affecting a com' Lined total of 50 million members, subscribers, or covered lives.
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From page 61... ...
Concepts of total quality management and continuous improvement evolved from efforts of Japanese manufacturers to improve products, increase productivity, and reduce costs (e.g., Deming, 1986; Imai, 1986; Juran, 1988~. During the 1980s, however, improvements in the quality of care occurred slowly, in part because the tools used to measure health care quality and monitor health care processes had not been developed and it was unclear how health care practitioners and systems could adapt the quality improvement tools developed for industrial environments (Berwick et al., 1991~.
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From page 62... ...
Nonetheless, by 1992 an IOM committee that examined clinical guidelines found growing interest in quality improvement models within health care settings (IOM, 1992~. The National Demonstration Project was an early effort to begin a transformation of health care and increase the use of quality improvement techniques (see Box 2.1)
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From page 64... ...
. Increasingly, accreditation agencies and purchasers expect organizations to have formal quality improvement programs and assess the quality improvement processes as part of their review of a health care organizations (e.g., AMBHA, 1995; CARE, 1996; Digital Equipment Corporation, 1995; NCQA, 1996; URAC, 1996~.
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From page 65... ...
As a result of this initiative, the managed behavioral health care organization responsible for the management of mental health and substance abuse services for the Massachusetts Medicaid program developed its own quality improvement program (Nelson et al., 1995~.
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From page 66... ...
In the public sector, purchasers need to make policy decisions on behalf of publicly insured individuals in the context of the local and regional political and economic environments. A majority of the health care quality information has been geared toward employers and other purchasers, but there is a growing emphasis on providing information that will help consumers select managed care plans that provide quality and an array of services.
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From page 67... ...
Some large purchasers, such as the Digital Equipment Corporation and Pacific Business Group on Health, have developed their own set of standards and monitoring guidelines and requirements and include those in their contracts with managed care organizations. Some other purchasers have adopted these standards, but others may in the future require use of the standards developed by the National Committee for Quality Assurance, which are based in part on the American Managed Behavioral Healthcare Association's performance measure set, or the report card developed by the Center for Mental Health Services.
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From page 68... ...
Ethi' cists agree that insurers, providers, and practitioners have a duty to safeguard the release of sensitive information through policy directives, information system pro' sections, and quality assurance mechanisms (IOM, 1993~. Confldentiality Regulations in Substance Abuse Treatment A unique aspect of treatment for alcoholism and drug abuse is the presence of federal regulations (42 CFR Part 2)
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From page 69... ...
Individuals have a responsibility to learn as much as they can about their health plans, including the nature of their benefits (Council on Ethical and Judi' cial Affairs, 1995~. Respect for autonomy assumes that a patient is capable of selL determination, but the capacity of an individual patient to make sound decisions that are in his or her best interest is influenced by the nature and course of the illness, as well as by individual personality and preferences.
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From page 70... ...
We believe that creative dialogue about quality with consumers and persons experiencing recovery from mental illness is a professional and ethical requirement that will change and increase with society's expectations. Sarah Stanley American Nurses Association Public Workshop, April 18, 1996, Washington, DC The role that patients play in managing their health is a theme common to the ethical concerns of confidentiality, patient autonomy, and the practitionerpatient relationship.
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From page 71... ...
One major trend is the increasing numbers of individuals enrolled in managed care plans, which take a variety of forms with different delivery and financing structures. A second trend is the increasing numbers of individuals in the public sector who are being enrolled in managed care plans, including a large number of individuals with chronic and severe health problems.
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From page 72... ...
Washington, DC The AMBHA Quality Improvement and Clinical Services Committee. AMA (American Medical Association)
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From page 73... ...
In press. Quality improvement for publicly-funded substance abuse treatment services.
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From page 74... ...
Paper submitted to the Substance Abuse and Mental Health Services Administration. JCAHO (Joint Commission on Accreditation of Healthcare Organizations)
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From page 75... ...
1996. Accreditation Standards for Managed Behavioral Healthcare Organizations.
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