Managing Managed Care Quality Improvement in Behavioral Health (1997) / Chapter Skim
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CHALLENGES IN DELIVERY OF BEHAVIORAL HEALTH CARE
CHALLENGES IN DELIVERY OF BEHAVIORAL HEALTH CARE
Pages 76-121
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From page 76... ...
This is changing, but there is a great need to improve the quality of mental health and substance abuse care delivered in primary care settings and also to better coordinate the care delivered in primary care and specialty sectors (IOM, 1996~. In addition, a significant portion of the public care system for individuals with the most disabling conditions extends beyond health care services to rehabilitative and support services, including housing, job counseling, literacy, and other programs.
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From page 77... ...
The dynamics of the three interrelated sectors privately funded primary and specialty health care and public health care systems are complex and also highly idiosyn' cratic from state to state, community to community, and plan to plan. An addi' tional layer of complexity comes from the historical separation of treatment sys' terns for mental health, drug abuse, alcohol abuse, and the primary care system in both the public and private sectors.
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From page 78... ...
One third of all criminal justice costs relate to mental health and substance abuse problems (Rice et al., 1990) , and general health care costs are significantly increased by the presence of these disorders (NAMHC, 1993~.
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From page 80... ...
A first factor is that, unlike most other health condi' lions, separate publicly managed health care systems are maintained for mental illness and substance abuse treatment. The publicly managed systems, with re' sponsibility divided between federal, state, and local governments, and also di' vided for mental illness and substance abuse care, permit a de facto catastrophic insurance function that allows private purchasers to strictly limit behavioral health care coverage because they know that they will not be leaving their em' ployees without an alternative.
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From page 81... ...
eValue of lost productivity of people who engage in criminal activity as a result of drug abuse.
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From page 82... ...
. pnys~c~ans Other professional6,5996457102,0473,197 services Nursing homes16,4785,4605,3164,5431,159 Drugs2,1911,167397406221 Support costs5,1697471,3521,4801,590 Indirect74,88735,43611,9969,85817,597 Morbiditya63,08334,16110,6942,19516,033 Noninstitutionalized58,98833,1058,8371,55615,490 population Institutionalized4,0951,0561,857639543 population Mortalityb11,8041,2751,3027,6631,564 Other Related Costs5,9603673,2461,3001,047 Direct2,292229599656808 Crime1,777178464508627 Social welfare51551135148181 administration Indirect3,6681382,647644239 Incarceration57358150164201 Family caregiving3,095802,49748038 NOTE 1990 costs are based on socioeconomic indexes applied to 1985 cost estimates.
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From page 83... ...
The services needed by these individuals may include housing supports, job training and rehabilitation, and a wide variety of other forms of assistance not considered and rarely funded by health insurance. Partly because of the disability associated with serious mental health and substance abuse prob' lems and partly because of poor private insurance coverage for treatment of these conditions, many people with serious conditions permanently lose employment and require income maintenance benefits for extended periods.
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From page 84... ...
It is exceedingly difficult if not impossible to generalize about the findings from treatment research in behavioral health, which includes drug abuse, alcohol abuse and alcoholism, and mental illness. Research histories stretch back decades in some cases, such as methadone maintenance, whereas other areas are relatively recent.
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From page 85... ...
Thus, generalizations are difficult to make with the existing data, but it would be appropriate to say that individuals can benefit from a variety of treatment strategies, including medication and psychotherapy or counseling, and that most practitioners seek to find an effective combination for each individual whom they treat. In the committee's view, then, the available evidence suggests that most forms of mental health and substance abuse treatment are effective for some of the many people affected by behavioral health problems (see Box 3.1)
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From page 86... ...
86 MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH ............................................................................................................................. T- ~ i } i ~-e~ - bases -- o-r~ ~ re-al-m-e-n-l~ o vl-e-n-l-a- -l-s-o-~ae-rs~ Ann- Aa-~-'c~lon - t '' 'i '''" '' '"''" ' ' ''t' ' '''" Q''" i'l"'' '''' ' ' ''' ' '"''' ' '"' '' '''' i'''''''' " ''' 1''''''''''''''' .............................................................................................................................
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From page 87... ...
Some studies have demonstrated that the integration of mental health and substance abuse professionals into primary care settings can improve patient out' comes with minimal changes in costs (Katon et al., 1995; Schulberg et al., 1995~. For this integration to work, clear clinical protocols and standards of care are needed, the mental health professionals should be on~site, and the relationship between the patient and the primary care provider should continue (IOM, 1996~.
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From page 88... ...
These systems sometimes consist of contracts with private mental health professionals who work on a capitated or fee~for~service basis. More often, they include plans with teams of psychiatrists, psychologists, family therapists, social workers, substance abuse counselors, or various combinations of these professionals.
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From page 89... ...
Peter Panzarino Vista Behavioral Health Public Workshop, May 17, 1996, In/ine, CA 89 A challenge for quality assurance is to assess, monitor, and regulate mental health and substance abuse care in primary care settings. This is a pervasive prob' lem, given the high percentage of mental health and substance abuse care pro' vided in these settings, but the breadth of the issue is tempered by the fact that there may be less risk of serious problems in this arena, in that many patients whose mental health and substance abuse problems are treated in primary care settings are less ill or disabled (IOM, 1996~.
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From page 90... ...
Until relatively recently, most health insurance did not include coverage for alcoholism. In 1968, alcoholics were excluded from 60 percent of the general hospitals, and 40 percent of the Blue Cross and Blue Shield plans explicitly excluded coverage for alcoholism treatment (NIAAA, 1974~.
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From page 91... ...
Individuals who have severe mental illness thus are a group with special needs under managed care, and advocates have identified specific concerns about how well those needs will be met. Less frequently identified as having special needs are those individuals who do not have severe mental illness but who have severe personality disorders or post-traumatic stress disorder.
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From page 92... ...
. However, individuals with serious or prolonged disorders or the parents of children with serious or prolonged disorders can easily use up their private insurance coverage benefits, creating economic hardships for them and their families.
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From page 93... ...
Untreated alcohol and drug dependency, for example, leads to increased utilization of emergency rooms and acute care hospitals. Simi' larly, men and women with serious mental illnesses may be more likely to be incarcerated for public order offenses if community services and supports are not provided.
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From page 94... ...
The weak' nesses of this sector include a lack of experience with managing comprehensive treatment and providing support to the more disabled population served in the public sector. More states are contracting with managed care firms to manage Medicaid behavioral health care services, but this is a new trend: currently, Med' icaid covers only a portion of the costs of mental health and substance abuse care and support for individuals in the public sector.
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From page 95... ...
VARIABILITY AT THE STATE LEVEL Although there is much variability from state to state, public behavioral health care services are coordinated and funded through state authorities for men' tat health and substance abuse. Those authorities revolve around organized sys' terns of care, are managed by designated not~for~profit agencies or units of county governments, and provide broad and diverse services.
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From page 96... ...
. Similarly, individuals with serious mental illnesses received poor care in alcoholism and drug abuse treatment programs (IOM, 1990a, b)
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From page 99... ...
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From page 100... ...
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From page 103... ...
, public mental health and substance abuse systems have improved dramatically in the past 15 years. Several forces and developments have contributed to this change.
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From page 104... ...
CSP promoted guidelines that urged a coordinated, community~based, long~term, and practical approach to car' ing for serious mental illness and provided a new and relevant conceptual model at a time when the field was searching for new solutions. Through a mix of na' tional meetings and targeted demonstration grants aimed at implementing the new model, CSP leveraged change in all the states.
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From page 105... ...
Contemporary treatment systems for alcoholism and drug abuse therefore began shortly after the repeal of Prohibition. In retrospect, the first programs were more likely to be based on personal experience than scientific research.
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From page 106... ...
At the federal level, Senator Harold Hughes, a freshman senator and former governor of Iowa who was in recovery, chaired public hearings across the nation during 1969 on the extent and eEects of alcoholism; publicly recognized men and women acknowledged their recoveries and testified to advocate for a national program to address alcoholism and to develop more humane systems of care (Hewitt, 1995~. The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (Hughes Act)
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From page 107... ...
Service systems in many areas continue to reflect this history and highlight a persistent tension between professional practitioners and experiential practitioners. Drug Abuse Treatment Passage of the Harrison Narcotic Act of 1914 marked a policy evolution from reliance on informal social influences to the vigorous use of enforcement, pros
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From page 108... ...
The only formal treatment programs for most individuals dependent on opiates, cocaine, or marijuana were two U.S. Public Health Service Narcotic Hospitals.
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From page 109... ...
NIMH consolidated the administration of research, training, and treatment related to drug abuse in the Division of Narcotic Addiction and Drug Abuse and funded community~based outpatient programs to provide assessments and aftercare (Besteman,1992~. A 1968 census of drug treatment programs identified 183 facilities (private and public)
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From page 110... ...
felt that this approach encouraged flexible care for the clients based on their individual needs and discouraged incentives to maximize revenues from each client through the provision of more services. From the beginning, therefore, publicly funded drug abuse treatment programs were organized and financed by using reimburse' ment and administrative structures that differed from those used by the rest of medical services.
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From page 111... ...
alcoholism and drug abuse treatment were not integrated with medical or psychiatric care, (2) drug abuse and crime policies frequently overlapped, and (3 ~ there was strong advocacy for autonomy in the alcoholism treatment field.
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From page 112... ...
project, begun in the 1980s, showed alarmingly high rates of substance abuse among offenders nationwide (IOM,1990b,1996~. With the simultaneous increase in the human immunodeficiency virus infection rate among intravenous drug abusers, efforts to direct treatment resources to the criminal justice population intensified.
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From page 113... ...
These programs may be operated as pretrial drug courts, the programs may be alternatives to incarcera' tion, or they may be treatment programs operated within correctional institu' lions. Funding for some of these programs is available through the Substance Abuse Prevention and Treatment Block Grant, and for others through CSAT's discretionary funds.
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From page 114... ...
Although specialty behavioral health companies are not yet contracting with prisons, the committee believes that it should be possible to provide appropriate substance abuse treatment within the criminal justice framework. Planning should involve the criminal justice and the addiction treatment experts and must address the lack of fit of the managed care principles with the current structure of the criminal justic sys tem.
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From page 115... ...
Individuals who had been trained in the public sector began moving to the private sector and established private companies to serve employers. The number of employers contracting for EAP services grew at a rapid pace during this decade as employers realized that they had to deal eEectively with mental health and substance abuse problems to be competitive in the marketplace.
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From page 116... ...
Although state agency integration is primarily an issue of merging stab and reducing dupli' cation, in most states, the mental health and substance abuse treatment systems are still distinct and separate. Thus, differences in patient populations, organize' tional cultures, programmatic philosophies, and funding mechanisms will con' tinue to inhibit full integration for some time.
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From page 117... ...
Rockville, MD Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Dole VP, Nyswander M
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From page 118... ...
1989. Drug Abuse Treatment: A National Study of Effectiveness.
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From page 119... ...
1982. Is substance abuse treatment effective?
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From page 120... ...
1990. The Economic Costs of Alcohol and Drug Abuse, and Mental Illness: 1985.
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From page 121... ...
1996. Preliminary Esti' mates From the 1995 National Household Survey on Drug Abuse.
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