Date: Nov. 20, 1996
Contacts: Dan Quinn, Media Relations Associate
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Better Ways Needed to Evaluate
Quality of Managed Behavioral Health Care
WASHINGTON -- Better protections are needed to ensure that managed care plans deliver high-quality care to the 52 million Americans with mental health and substance abuse problems, a committee of the Institute of Medicine says in a new report.* At a time when insurance benefits are shifting rapidly to managed care, it is important that government, accreditation organizations, and managed care plans take steps to protect consumers and to monitor the care being given. Although the report focuses primarily on behavioral health care -- which includes the prevention and treatment of mental health and substance abuse problems -- its recommendations are directly relevant to the entire health care system.
"The current accreditation system for health plans does not provide a complete picture of their performance in delivering high-quality care," said Jerome Grossman, chairman and chief executive officer of Health Quality LLC, Boston. "The evolving system of accreditation needs to be made more sensitive to the experiences of those individuals who rely on managed care, especially those who need access to behavioral health care."
Currently 60 percent of the U.S. population is enrolled in a managed care plan, many of which include benefits for mental health care or substance abuse. Each year, 52 million Americans have some kind of mental health or substance abuse problem. Quality-control measures in health care include voluntary accreditation by independent agencies like the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance, as well as the demands made on insurers by purchasers, which may include private corporations or public entities.
The report recommends that:
> Managed care organizations should provide consumers with a clear description of a plan's benefits and create straightforward grievance procedures. And they should take steps to maintain patient confidentiality and eliminate so-called "gag clauses" or other limitations that may prevent a clinician from discussing treatment options or providing appropriate care.
> Accreditation organizations should focus on areas associated with effective treatment, such as whether a patient experiences fewer symptoms or returns to work or school. Most accreditation agencies now primarily assess the structure and process of care, rather than the results, the report says.
> The federal and state governments should encourage the development of "report cards" or other materials to help inform consumers and their families about the quality of specific plans.
> The federal government should monitor the effectiveness of quality assurance and accreditation, and should promote improvements in the tools used to measure health care quality.
> Primary care clinicians should be trained to better recognize patients with mental health and substance abuse problems, and either treat them or refer them to specialty providers such as psychiatrists, psychologists, or social workers.
A major concern with managed behavioral health care results from having two distinct financing arrangements -- one for publicly funded state programs, as well as Medicaid and Medicare, and another for private health insurance. Critics of managed care fear that market forces could allow health plans to transfer an increasing share of costs to the consumer, to effectively screen out all but the healthiest enrollees from participating in the plan, or to shift costly care that might not be covered by managed care to the underfunded public-financed system. The report says there is currently no effective way to judge whether any of these practices is taking place, and recommends that accreditation agencies and public- and private-sector purchasers each develop criteria and guidelines to identify potential problems and correct them.
The report recommends that purchasers of managed care -- and especially of behavioral health care -- involve consumers and their families in treatment decisions and in measurements of patient satisfaction and treatment effectiveness. Accreditation agencies should evaluate the extent to which consumers are involved in treatment decisions; they should include consumers and their families, as well as practitioners and researchers, in their review of quality.
The study was funded by U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. The Institute of Medicine is a private, non-profit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster is attached.
Read the full text of <Managing Managed Care> for free on the Web, as well as more than 1,800 other publications from the National Academies. Printed copies are available for purchase from the National Academy Press Web site or at the mailing address in the letterhead; tel. (202) 334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information at the letterhead address (contacts listed above).
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Institute of Medicine
Division of Neuroscience and Behavioral Health
Division of Health Care Services
Committee on Quality Assurance and Accreditation Guidelines for Managed Behavorial Health Care
Jerome H. Grossman (*)(chair)
Chairman and Chief Executive Officer
Health Quality LLC
Scholar-in-Residence, Institute of Medicine
Mental Health Advocate
John J. Burke
Executive Vice President, Value Behavioral Health
Falls Church, Va.
M. Audrey Burnam
Senior Behavioral Scientist and Co-Director, Drug Policy Research Center
Santa Monica, Calif.
Illinois Department of Alcoholism and Substance Abuse
Molly Joel Coye (*)
Executive Vice President, Strategic Development
Lynne M. DeGrande
President, DeGrande & Associates, and
Senior Consultant, Employee Assistance Program
General Motors Corp.
Richard G. Frank
Professor of Health Economics
Department of Health Care Policy
Harvard Medical School
John E. Franklin Jr.
Associate Professor of Psychiatry
Northwestern University Medical School
Michael F. Hogan
Ohio Department of Mental Health
Director, Substance Abuse Group
Institute for Health Policy, Heller Graduate School
J. Michael McGinnis (#)
Former Deputy Assistant Secretary for Health, and
Scholar-in-Residence, Commission on Behavioral and Social Sciences and Education
National Research Council
Rhonda J. Robinson-Beale
Senior Associate Medical Director
Coordinated Behavioral Health Management
Health Alliance Plan
Alex R. Rodriguez
Vice President and Medical Director
National Account Consortium Inc.
Steven S. Sharfstein
President, Medical Director, and Chief Executive Officer
The Sheppard Pratt Health System
Donald L. Shumway
Co-Director, Self-Determination for Persons with Development Disabilities, Institute on Disability
University of New Hampshire
Senior Scientist, Alcohol Research Group
Western Consortium for Public Health, and
School of Public Health
University of California
INSTITUTE OF MEDICINE STAFF
Senior Program Officer, Division of Health Care Services
Director, Division of Neuroscience and Behavioral Health
* Member, Institute of Medicine
# Resigned from committee, August 1996