Managing Managed Care Quality Improvement in Behavioral Health (1997) / Chapter Skim
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SUMMARY
SUMMARY
Pages 1-14
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have turned to managed behavioral health care companies to control costs and improve quality and access for mental health and substance abuse care. Purchasers share with responsible managed care organizations a unifying goal of a more responsive health care delivery system, one that is both more efficient and more eEective.
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The framework could then be used to assist in the purchase and delivery of the most eEective managed behavioral health care at the lowest appropriate cost for consumers of publicly and privately financed care. The 17 members of the committee were chosen for their expertise with national accreditation processes and procedures, public and private managed care organizations, employee assistance programs, corporate and public purchasing of mental health and substance abuse services, public and private medical administration, and health services research.
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Another challenge is that much of behavioral health care, perhaps as many as half of all episodes of care, is provided in primary care settings, not in specialty programs. Despite clinical practice guidelines, continuing education courses, and other training programs, primary care providers tend to underdiagnose depression, substance abuse, and other behavioral health problems.
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Well~developed public and private health care and behavioral health care plans will promote access to men' tat health and substance abuse services. Enrollees that access care promptly and early in their illness episode may require less intensive care, and with appropriate continuing support they may be less likely to experience relapses.
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Many methods are used to assess quality: accreditation, licensing and certifi' cation, credentialing, auditing, peer review, performance monitoring, contracts, clinical standards and guidelines, consumer satisfaction surveys, and report cards. Some private payers have developed their own standards for HMOs and other managed care organizations that provide care and are also urging contracted orga' nizations to collect and publicly report information on their performance.
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To those who are responsible for purchasing care, the absence of consensus on quality measurements is a challenge. The committee developed a set of findings and recommendations in 12 areas: structure and financing; accreditation; consumer involvement; cultural competence; special populations; research; workplace; wraparound services; children and adolescents; clinical practice guidelines; primary care; and ethical concerns.
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2.2.1 When plans contract or subcontract for the management and delivery of behavioral health care services (e.g., health maintenance organizations contracting with carved-out managed behavioral health care firms) , purchasers can benefit from independent audits of the contractor regarding the level of adherence to prespecified standards of performance with respect to quality.
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. Role of State Governments 2.4 The role of state governments in consumer protection should include the following: 2.4.1 Support the development of consumer protection standards for managed behavioral health care by state mental health and substance abuse agencies, state Medicaid agencies, state insurance departments, state licensing boards, state hospitals, and state child welfare agencies.
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in the development, implementation, and use of standards. Provider Inclusion 2.6 Because managed care methods are increasingly applied to public systems, accreditation bodies and managed care plans should evaluate the inclusion of a variety of types of practitioners, including substance abuse counselors and mental health workers, in provider panels; collect information on practitioner electiveness; and remove any practitioners from networks only for performance reasons (e.g., poor outcomes and poor consumer satisfaction)
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The Substance Abuse and Mental Health Services Administration (SAMHSA) should work with other federal agencies to develop a plan to con' duct such research.
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8.2 To maximize full functioning for individuals with severe and persistent mental illness, and to optimize conditions supporting recovery for individuals with chronic substance abuse problems, wraparound services such as social welfare, housing, vocational, and rehabilitative services should be available and should be coordinated. 8.3 For children and adolescents with severe emotional disturbances, ecu'
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should identify exemplary models of linking behavioral health treatment and prevention programs for children and adores' cents to address suicide, substance abuse, and other areas. 9.3 The Substance Abuse and Mental Health Services Administration (SAMHSA)
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12. ETHICAL CONCERNS Recommendations include 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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, Health Care Financing Agency (HCFA) , and Agency for Health Care Policy and Research (AHCPR)
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