The Provision of Mental Health Services in Managed Care Organizations

Quality Management

In recent years, the health care industry has focused on assessing health care quality in behavioral health and other arenas (Edmunds et al., 1997; McCorry et al., 2000; Merrick et al., 2002). This stems in part from the move to managed care in general and the growth of the managed behavioral health care industry, which have both raised concerns and held out the promise of improved quality. Accreditation organizations such as the National Committee for Quality Assurance (NCQA), MBHO industry groups such as the American Managed Behavioral Healthcare Association, consumer-and purchaser-oriented organizations such as the Foundation for Accountability, and purchasers themselves have played a role in driving the adoption of quality management approaches through accreditation and performance measurement systems (FACCT, 2001; NCQA, 2001). While a literature on specific quality improvement initiatives exists, this study is the first to provide estimates of MCOs' use of a range of behavioral health quality management activities based on a nationally representative sample (Merrick et al., 2002).

Out of the range of possible activities that MCOs can conduct to measure and ultimately improve quality, we asked about four commonly mentioned activities: whether patient satisfaction surveys that ask about behavioral health services are conducted at least annually, whether clinical outcomes are assessed for at least some behavioral health patients, whether behavioral health performance indicators are tracked, and whether there are practice guidelines for major depressive disorder, schizophrenia, and panic disorder. This chapter reports key findings regarding these quality management activities.

Prevalence of Behavioral Health Quality Activities

Most products use at least one of these four quality-related activities (Figure VIII.1). More than two-thirds of products conduct patient satisfaction surveys that ask about behavioral health services (70%), track behavioral health performance indicators (73%), and have practice guidelines for at least one of the three mental disorders selected (67%). Fewer than half (49%) conduct clinical outcomes assessments. The prevalence of quality activities differs across product types. Significantly fewer PPOs than HMOs participate in quality-related activities. For example, less than half of PPOs conduct patient satisfaction surveys, compared with almost 90% of HMOs. With respect to contracting arrangements, products with specialty contracts are most likely to conduct each of the quality activities (data not shown).

MCOs' Reporting of Results

MCOs report quality-related findings to a variety of stakeholders (Figure VIII.2). When patient satisfaction surveys are conducted, for example, results most frequently are reported to the MCO's quality assurance committee (100%), followed by external organizations (85%), clinicians (regarding overall results, 78%), and enrollees (66%). Few of the products that conduct these surveys (17%) report providing patient satisfaction results to individual clinicians regarding their own clients.

Practice Guidelines for Selected Mental Health Disorders

The study asked whether MCOs had practice guidelines for any of three mental disorders. Most products (66%) provide guidelines for major depressive disorder (Figure VIII.3). Less than half report having guidelines for the treatment of panic disorder and schizophrenia. The most common source of guidelines for each disorder is self-developed guidelines only (Figure VIII.4). Very few products report using only commercially developed practice guidelines, while substantial proportions use federal agency or professional organization guidelines only, or a combination of sources.

Quality Assurance Committees for Mental Health Services

Three-quarters of all products reported having an MCO-level committee to oversee quality assurance programs for mental health and
substance abuse services (Figure VIII.5). Nearly all such committees include specialty mental health and substance abuse providers, while close to half include primary care providers (Table VIII.1). Very few include consumers or other enrollees.

Discussion

Most managed care products conduct patient satisfaction surveys, track performance indicators, and have practice guidelines for the mental health disorders the study asked about. Clinical outcomes assessment was less common. One MBHO executive told us: "It's no wonder that less emphasis is placed on measuring outcomes. Outcomes are difficult to measure, members and providers are often reluctant to participate, and outcomes measurement can be very costly."

The higher proportion of HMOs using these activities suggests that the traditionally "more managed" products may have structures that facilitate quality management, or that these products have responded to external pressures such as accreditation organizations, which until recently focused on mainly HMOs. Alternatively, the fact that specialty contract products more often conduct these activities raises the possibility that this contracting arrangement (more common in HMOs) affects the prevalence of activities. It is also important to understand that while these activities seem useful by providing tools with which quality can be improved, our results cannot tell us about differences in the actual quality of care that may result from quality management efforts.

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