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Organization & Financing

SAMHSA Managed Care Initiative Training Sessions

February 1997

Dates: February 5, 1997-Parklawn Conference Center, Rockville, MD
February 25, 1997-American Psychiatric Association, Washington, D.C.

Title: Framework for Quality Assessment and Accountability A discussion of the forthcoming report of the Institute of Medicine - Managing Managed Care: Quality Improvement in Behavioral Health

Speakers:	Jeff Buck, Ph.D., Director Center for Mental Health Services Substance Abuse and Mental Health Services Administration (moderator for Feb. 25 meeting only)
	John Burke, MA, CEAP, Executive Vice President Workplace Services, Value and Behavioral Health Member, Institute of Medicine committee (Feb. 25 meeting only)
	Mady Chalk, Ph.D., Director Managed Care Initiatives Center for Substance Abuse Treatment (moderator for Feb. 5 meeting only)
	Margo Edmunds, Ph.D., Study Director Division of Health Care Services and Division of Neuroscience and Behavioral Health Institute of Medicine
	Constance Pechura, Ph.D., Director Division of Neuroscience and Behavioral Medicine Institute of Medicine

Rapporteur: Michele R. Bupp, TASCON, Inc.

Summary:

Dr. Chalk (Feb. 5 only)/Dr. Buck (Feb. 25 only) welcomed the group and explained that the Substance Abuse and Mental Health Services Administration (SAMHSA) had funded the development of the study-Managing Managed Care: Quality Improvement in Behavioral Health-that was the subject of the meeting. The study was conducted by the Institute of Medicine (IOM).

Dr. Chalk/Dr. Buck spoke briefly about the characteristics of managed care. Managed care programs require a network of providers, such as integrated health maintenance organizations (HMOs) or a special contract. HMOs have utilization management that includes a clinical protocol, prior approval, case management, and quality management. Some of these elements are more effective than others in assuring an effective managed care program. For example, examining the patterns of service is more successful in containing costs than the prior approval method.

Dr. Chalk/Dr. Buck then introduced Drs. Constance Pechura and Margo Edmunds from the IOM, as well as Mr. John Burke, the workplace services representative of the IOM committee. The IOM is a nonprofit organization that operates under a charter of the National Academy of Sciences, which was established in 1863 under President Lincoln. The IOM provides policy advice to the Federal Government, foundations, and industry. The IOM comprises the Neuroscience and Behavioral Health and the Health Care Services divisions. Besides Drs. Edmunds and Pechura, the IOM staff involved in the managed care project included Molla Donaldson, Carrie Ingalls, Amelia Mathis, Terri Scanlan, and Thomas Wetterhan. The Managing Managed Care: Quality Improvement in Behavioral Health study is a component of the IOM Quality Initiative.

Mr. Burke commented on the compatibility of the IOM committee, of which he was a participant. He found the committee to exhibit teamwork and to be a "bonding, tight knit group." He explained that he brought the focus of workplace issues to the committee members. He believes that the quality of health and medical care impacts the workplace greatly.

Dr. Pechura defined some common terms used in managed care methodology-behavioral health: managed care for mental health and substance abuse; consumers: individuals who are, have been, or may be receiving care; practitioners: individuals who treat other individuals; and providers: a program, facility, or organization that delivers care. She then described the IOM committee that developed the study. It comprised accreditation organizations, managed care organizations (MCOs), health services research, medical administration, and workplace health services. The committee members were Jerome Grossman, Chair, Robert Boorstin, John J. Burke, M. Audrey Burnam, Barbara Cimaglio, Molly Joel Coye, Lynne M. DeGrande, Richard G. Frank, John E. Franklin, Jr., Michael F. Hogan, Dennis McCarty, Rhonda Robinson-Beale, Alex Rodriguez, Steven S. Sharfstein, Donald L. Shumway, and Constance M. Weisner. They are specialists in the fields of employee assistance, internal medicine, occupational medicine, psychiatry, psychology, public health, and social work. The committee met five times and organized two public workshops.

The IOM committee was charged to develop a framework for the development, use, and evaluation of performance indicators, accreditation standards, and quality improvement activities. This framework would be used by consumers and other purchasers of publicly and privately financed behavioral health care organizations. The second charge was to purchase the most effective managed behavioral health care at the lowest appropriate price. The multiple stakeholders in this venture include accreditation organizations, Federal and State Governments, community-based organizations, MCOs, consumers, and health services researchers.

The committee first developed a set of principles to guide its work. The committee members believed that the most important elements of these principles were consumer protection, evidence-based approaches, opportunities and risks of managed care, special populations, and ethical issues. With the input from the liaison panels, public hearings, and literature reviews, as well as relying on the expertise of the group, the members developed the findings or conclusions and recommendations that are contained in the report.

According to Dr. Edmunds, the committee recommended the Donabedian Framework for Quality Measurement as a useful method to measure the impact of quality. Impact varies depending on the levels of responsibility for quality of care within an organization, the regulatory mechanisms that apply, and the nature and extent of the relevant outcomes of the research base. (See page 6, Figure 1.2, of the meeting handout for a complete Donabedian Framework.) This conceptual framework includes types of services, staffing, and adherence to codes; access: insurance coverage and ability to receive appropriate services; process: procedures and courses of treatment; practice guidelines; and outcomes: changes after treatment.

Dr. Edmunds then continued the presentation. She explained that the "heart" of the committee's work is the recommendations. The findings on structure and financing for health care revealed that 1) limited coverage can lead to undertreatment and poor outcomes; 2) expensive care is often shifted from a private to a public system (cost shifting); and 3) fragmented funding leads to fragmented treatment. In response to these findings, the following recommendations were made: 1) accreditation organizations and purchasers should develop criteria and guidelines that recognize and measure dumping, skimming, and cost-shifting; and 2) accreditation organizations and purchasers should specify rewards for those that give appropriate care and penalties or adhere to the regulations.

Concerning accreditation, the committee found that 1) accreditation is in an infant stage in the managed care and behavioral health arenas; 2) multiple competing organizations perform measurement, reporting, and accreditation activities; and 3) the current focus is more on structure and process than on outcomes.

In response to its findings, the committee recommended the following accreditation standards for-

1. Monitoring Quality of Care

• Purchasers and other stakeholders should adopt quality improvement methods.
• Accreditation should focus on problem areas with risks related to quality, such as utilization review, vulnerable groups, and high-frequency conditions.
• External, independent audits should be used to validate data quality.

2. Contracting

• Standards for quality of care should be clearly addressed in contract language.
• Independent audits of contractors should adhere to standards.
• There should be positive incentives for meeting or exceeding standards and penalties for substandard performance.

3. Role of the Federal Government in Consumer Protection

• Promote improvement and use of performance measures for managed care.
• Monitor and study use and effectiveness of quality assurance, accreditation, and measurement of performance and outcomes.
• Establish minimum standards for accreditation organizations to achieve deemed status. (Government agencies sometimes require accreditation by a specific organization as a condition for operation, reimbursement, or other activity. That organization is "deemed" to act in the public interest and thus has "deemed status.")

4. Role of State Governments in Consumer Protection

• Support the development of consumer protection standards by state agencies with involvement of consumer groups.
• Balance consumer protection with innovation.
  (Dr. Edmunds related an example of care. A state mental health director in Ohio worked in sweat lodges, which are a popular form of treatment for mental illnesses on Native-American reservations. Although this type of treatment does not have the same outcome measures as do traditional programs, these patients have found it very useful for them and their families.
• Consider deemed status arrangements.

5. Recommendations for All Accreditation Agencies:

• Include all stakeholders-purchasers, practitioners, and consumers-in the preparation process.
• Encourage the development of report cards to help consumers and families.
• Value external, independent audits.
• Evaluate the use of deemed status, whereby the government recognizes accreditation standards of specific organizations.

Committee appointees to ensure consideration of the importance of the consumer found that-

• Consumers and families want to share the decisionmaking in treatment, standard setting, and performance measurement.
• The Congressional Medal of Honor Society report card contains the most consumer involvement.
  

  The committee recommended that-

  • The participation of consumers in treatment decisions and in measurement of satisfaction and treatment effectiveness is beneficial.
  • Accreditation should assess the degree of consumer involvement.
  • Consumers should work with other stakeholders on quality measurement.

Committee appointees to ensure cultural competence found that-

• Racial and ethnic minorities frequently lack access to culturally appropriate care.
• An effort to create smaller, more efficient provider networks may exclude culturally sensitive providers.
• A research base for cultural healing practices is lacking.

  The committee recommended that-

  • Health plans be responsive to the cultural needs of the populations served.
  • Practitioners of culturally appropriate treatments not be excluded.
  • Health plans have a way to evaluate new techniques and providers.

Committee appointees to ensure equal attention to special populations found that-

• People with disabilities can lack access to appropriate care.
• Lack of child care can be a barrier to treatment access.
• Individuals with co-occurring substance abuse and mental health problems need coordinated care to maintain recovery.

  The committee recommended that-

  • Research is needed to identify incentives for health plans and to serve vulnerable populations.
  • Plans that serve distinct populations should evaluate their needs.
  • All plans should meet core standards; supplemental standards can be developed for special populations.

Committee appointees to ensure appropriate and adequate research methods found that-

• Health services research stimulates collaboration.
• Research and practice interact too little.
• Outcomes research is not linked to clinical practice, accreditation, or quality improvement.
• The Federal Government plays a key role in supporting health services research.

  The committee recommended that-

  • Research in collaborative health services should continually develop.
  • Researchers should use managed care and community-based settings to help develop standards.

Committee appointees for the workplace found that-

• Safe and supportive work environments are needed.
• A response to federal legislation is needed concerning, for example, the Family and Medical Leave Act and the Americans with Disabilities Act.
• The workplace environment is a prime arena to address behavioral health problems.

  Committee appointees recommended that-

  • Employers should investigate wellness activities, employee assistance programs, and health risk reduction initiatives that enhance prevention, early intervention, access, and treatment adherence for health and behavioral health problems.

Committee appointees for wraparound services found that-

• To maintain long-term recovery, social aspects of consumers' lives need to be addressed as part of behavioral health care.
• Medical and managed-care models rarely include rehabilitative and support services (also known as wraparound and enabling services).

  Committee appointees recommended that-

  • Wraparound services, such as social welfare, housing, vocational, and rehabilitative services be available and well coordinated.
  • Educational and family support services for children and adolescents with severe emotional disturbances be coordinated with health care.

Committee appointees for children and adolescents found that-

• Services for children and adolescents are fragmented across many agencies, for example, mental health, child protection, and juvenile justice.
• The children is the only focus, not the family.
• Developmentally appropriate treatment and prevention models are needed for teens.
• Prevention and treatment are not linked.

  Committee appointees recommended that-

  • Guidelines should be developed to link outcomes research, performance standards, and accreditation.
  • The implementation of research is needed.
  • Practitioners and consumers should be included in guideline development.

Committee appointees for clinical practice found that-

• The development of guidelines is not always systematic or linked to research.
• Little is known about successful implementation strategies.
• Accreditation tends to measure whether guidelines are in place but not the quality or contents of the guidelines.

  Committee appointees recommended that-

  • The development of guidelines should be linked to outcome research, performance standards, and accreditation.
  • Implementing research with clinical practice is needed.
  • Practitioners and consumers should be included in guideline development.

• 10 to 20 percent of the population consults a primary care physician for a behavioral health problem.
• Care is fragmented among primary care, mental health, and substance abuse services.
• Few guidelines exist for behavioral health treatment in primary care.

  The committee recommended that-

  • Organizations place disincentives for the expanded role of primary care in the provision of mental health services. (This endorses the IOM 1996 report on primary care).
  • MCOs should include alcohol and other drug abuse problems as defined areas of expertise.

• Health care ethics should include principles about autonomy, access, informed consent, and confidentiality.
• Ethical challenges exist in traditional fee-for-service and managed care settings but with different incentives and risks.
• Cultural competence and sensitivity are ethical issues.
• The members recommended that managed care organizations address ethical risks, to including the following:
  1. A clear description of the plan, benefits, and grievance procedures
  2. Accessible and responsible grievance, complaint, and appeals procedures
  3. Effective strategies to maintain confidentiality while coordinating care
  4. Culturally appropriate and gender-specific services for practitioners in the network
  5. Consumer surveys and measures of consumer satisfaction
  6. Consumer representation in policy development and grievance resolution
  7. Continuous improvement protocols
  8. No contractual or other limitations concerning discussion of appropriate treatment options. (Always taking better care of consumers who are in treatment.)

In summary, the IOM committee has taken a very strong approach to consumer protection. Its members promote the use of performance measurement and effectiveness of accreditation for State and Federal Governments; believe that the contracts between purchasers and providers are key; and hold quality improvement and effectiveness in the health care arena in the highest regard.

Dr. Chalk/Dr. Buck concluded the meeting and stated that there are three important components to the contract process: 1) performance indicators, such as the guidelines for "Best and Final"; 2) financial incentives; and 3) research collaboration. Each emphasized the importance of examining each contract that SAMHSA funds to determine how these contracts are awarded. From this information, it is possible to identify problems and demonstrate appropriate solutions for contract management. One current problem that the moderator sees is the lack of enforcement of contract penalties.

Question and Answer Session I
(February 5, 1997-SAMHSA Group)

1.
Q: Do contractual or other limitations concerning appropriate treatment options exist among health plans?

A: (Dr. Chalk) There is a battle about how to deal with gag clauses. The articles in the newspapers about the American Association for Health Plans (AAHP), which represents the HMO industry, say that treatment will be available for all and there will be no problems in obtaining plan coverage. These statements are very misleading. I have no doubt that the need for our study came, in part, from these series of articles. There are conflicting legal opinions about nurse practitioners, for example, whether they are as qualified as physicians.

(Dr. Edmunds) There is federal legislation for gag clauses, which says that personnel can discuss only the treatment options that are available for the personnel they work for. Treatment by bone marrow transplants is something that frequently comes up. So, if a great treatment is available, a provider cannot recommend it if the insurance will not pay for it. Care coordination is another important issue in health care because shared medical records often cause a patient to lose privacy. Providers are sharing and comparing information about a patient's history.

(Dr. Pechura) One of the reasons I was so happy with this study is that it opens the ears of Congress to a discussion of gag rules and what really makes sense.

2.
Q: What is the coverage in plans for schizophrenia?

A: (Dr. Chalk) We have discovered in our studies (one study was featured in a SAMHSA publication) what different states are doing. States are contracting with MCOs in the public and private sectors. Consumers are at a disadvantage because they do not know how to get the behavioral health coverage they need: They do not know where one plan ends and another begins. Some contracts serve only special populations, such as for chronic substance abusers and the chronically mentally ill, and are not broad enough to cover all need levels.

3.
Q: How does the committee determine the definition of "culturally-appropriate and gender-specific"? (My experience is with Latinos in South Texas.)

A: (Dr. Edmunds) Certainly there is a difference, for example, between Latinos in New York City, where there are a lot of managed care networks, and rural areas, where very few exist. In its concern for minority groups, we studied alternative therapies, such as acupuncture for detoxification, and also found that there are several alternatives to certain medications and surgery. You will find that even though there is very solid evidence that these therapies work, many people do not believe that these methods are successful because of their personal biases.

(Dr. Pechura) In many cases, we just have not progressed to the point where we accept these methods; there is no backdrop for alternative therapy. So what should we do? We need to raise the level of awareness, so that when these issues are talked about, there is some level of understanding.

(Dr. Chalk) There is one recommendation in our report that alternative therapies be allowed into the network. We need to place these therapies in the network and then perform appropriate studies to see how they work. We need to ask ourselves: Are they successful?

4.
Q: How do plans reach out to alcohol and drug abuse populations with alternative therapies?

A: (Dr. Edmunds) The committee discussed performance measures for providers. The AMA (American Medical Association), I'm sure, would have something to say about that. There is a long tradition where providers make decisions without taking outside sources and reports into account. When outside research is considered, they often change their minds about a previous decision. I understand their dilemmas because we (the committee) also changed our decisions when we examined supporting material.

5.
Q: What about a therapy that is not alternative? How do plans determine what kinds of therapies are necessary?

A: (Dr. Edmunds) With depression diagnoses, for example, one can be mildly depressed and still should be seen right away. Early diagnosis and treatment are the original concept of provider networks. Unfortunately, the process does not work that way.

(Dr. Chalk) The problem with provider networks is that even though they have a larger base, there are many providers being thrown out of networks in the behavioral health area because the plans believe the providers are 1) seeing patients for too many sessions (visits); 2) costing too much money for lab tests, etc.; and 3) requiring too many expensive prescriptions. Unless the states define in their contracts that the provider sets the standards for the needs of the patients and the HMOs must support (and pay for) what the provider prescribes, then HMOs will continue to deny payment for treatments they deem "excessive."

(Dr. Edmunds) One of our consumer advisors on the committee asked us if plans can assure patients that they will be able to be treated by a fundamental Christian or a Chinese-American doctor, for example, if that is what patients want. The answer is probably "no," but there is quite a bit of diversity in this country; we should try and match consumers up with the providers of their choice. Of course, if we wanted a health care system to really work well to take care of us, it would not be the one we have now.

6.
Q: Who decides who gets into the network?

A: (Dr. Edmunds) Objective performance measures determine that.

7.
Q: Does the IOM task force set performance measures?

A: (Dr. Edmunds) It is actually the clinical prevention task force that develops guidelines. I think it is a model. It was a multiyear effort and there were at least 300 people involved. I have tried to ask the NCQA (National Committee for Quality Assurance) how much it costs them to develop guidelines, and they would not tell me. I am sure it takes thousands of dollars.

(Dr. Pechura) We (the committee) are a convening function, but we cannot drive or develop guidelines.

8.
Q: Is it the function of NIDA (National Institute on Drug Abuse), NIMH (National Institute on Mental Health), and others to work together to promote these managed care regulatory efforts?

A: (Dr. Chalk) There are a couple of other activities going on that look at clinical practice guidelines and how to grapple with them. But we are going to have to take the lead on it. We do have a current IOM study that we cofunded with NIDA called "What are the Barriers and Opportunities for Community-Based Treatment Organizations to Participate in and Make Use of Research." This study is directly related to the discussion we are having today. Community-based treatment organizations may have to change their research method; it may not be a matter of just changing the report method. I certainly welcome people who want to push issues inside NIDA.

Question and Answer Session II
(February 25, 1997-National Mental Health Liaison Group)

1.
Q: I feel strongly that "outreach" should be included in your study? I do not see it showing up in your study. It is an important element of quality. It is also an excellent way to reach your audience-the consumer.

A: (Dr. Edmunds) It is not formally included, but in some ways we have included it.

(Mr. Burke) We have not spelled it out, but we have used outreach in the workplace area, my area, where we have spoken to workplace specialists.

(Dr. Buck) This summary (Managing Managed Care: Quality Improvement in Behavioral Health) does not contain all of the committee's findings. An elaboration of the full report is scheduled for production in April or May. I would advise you to pick up a copy of the full report. It is very comprehensive and complete. We are giving quite a few copies to your association (American Psychiatric Association).

2.
Q: I am talking about formal outreach of services and quality. Is that included in the survey?

A: (Mr. Burke) We (Value Behavioral Health) have a document in development at this time that expounds on the value of outreach in assessing health quality. I can get your name and number and see that you get a copy when it is published.

3.
Q: What is the obligation of your contractor to develop data, what kind of data, and so on?

A: (Dr. Edmunds) We have been working with the National Committee on Quality Assurance (NCQA) to develop general health care data. So, it is kind of an eye opener to be involved in this development .

(Mr. Burke) Actually, we (Value Behavioral Health) have been working with them (NCQA) for several years.

4.
Q: Have you distinguished mental health data from other health care problems in your report?

A: (Mr. Burke) Mental health and substance abuse problems are important in managing managed care and an important part of our study. It is good to note here that mental health and substance abuse issues are distinctly different from other health problems, such as diabetes and heart disease, and need greater integration of services. Thus, the committee has tried throughout the report to underscore a critical distinction between the unique aspects of the structure of behavioral health care delivery and the nature of the disorders themselves, which are not unique, but can range from a single episode of illness to chronic, recurrent, and disabling conditions.

(Dr. Edmunds) I really recommend reading our full report when it is available next month.

5.
Q: How did the committee develop accurate and appropriate case-mix and risk-adjustment models for the report?

A: (Dr. Edmunds) The committee believed that the further development of analytical tools was necessary for a comprehensive report, and that this evidence base needed to be expanded before detailed recommendations were made. In addition, development, for example, required collaboration among various components of the public and private sectors.