Annotated Bibliography - Quality Assurance

This special supplementary section of the bibliography provides an independently produced annotated bibliography on managed behavioural healthcare prepared for the US Substance Abuse and Mental Health Services Administration; please see the first page of the supplement for recommended citation information.

Table of Contents

  1. Introduction
  2. Benefit and System Design
  3. Capitation
  4. Community Mental Health Services
  5. Diagnosis-Related Groups (DRGs)
  6. Economics, Forecasting, and Pricing
  7. Employee Assistance Programs (EAPs)
  8. Health Maintenance Organizations (HMOs)
  9. Law and Ethics
  10. Provider Issues
  11. Public Sector
  12. Quality Assurance and Outcomes
  13. Special Populations
    1. Children
    2. Elderly
    3. Ethnic Groups
    4. Women
  14. Substance Abuse
  15. Training and Education
  16. Utilization Management
  17. Author Index
  18. Keyword Index

Quality Assurance and Outcomes

286. Bartlett, J., & Cohen, J. (1993). Building an accountable, improvable delivery system. Administration and Policy in Mental Health, 21, 51-58.

The authors describe the efforts of their organization, MCC Behavioral Care, Inc., to collect outcome data for the purpose of improving managed mental health and substance abuse treat-ment. They say three conditions are necessary to drive improvement in overall system function: that the process be ongoing, that data generated be sound and relevant, and that the process become an integral part of an organization’s regular operations. MCC contracted with the Institute for Health Services Research at the University of Minnesota to provide the scientific rigor needed for providing an accountable, improvable delivery system. MCC hopes that this investment in continuous data collection will drive forward the state of the art, both within MCC and in the field in general, and that it holds great promise for the continual improve-ment in quality and cost-effectiveness of managed approaches in mental health and substance abuse care.
Keywords: performance measurement, quality assurance

287. Berlant, J. L. (1992). Quality assurance in managed mental health. In S. Feldman (Ed.), Managed mental health services (1st ed., pp. 201-222). Springfield, IL: Charles C. Thomas.

This chapter discusses the wide range in the definition of quality assurance systems, from "standard practice" to the "avoidance of adverse outcomes" to "optimal care." The author discusses constraints on developing and maintaining a good quality assurance system. A 10- step monitoring and evaluation plan is outlined, as well as guidelines that many hospitals have found useful in implementing internal evaluation. The author argues that despite claims to the contrary, mental health services are amenable to quality assurance. Tools for quality assurance are described. The author concludes with several directions for quality assurance in managed mental health that appear promising, and suggests that a national data bank should be established for the collection, analysis, and dissemination of quality assessment findings in mental health.
Keywords: quality assurance, technical assistance

288. Borenstein, D. B. (1990). Managed care: A means of rationing psychiatric treatment. Hospital and Community Psychiatry, 41, 1095-1098.

Employers are looking increasingly to managed care and utilization review to reduce their medical expenses. This paper describes some of the problems experienced by patients and psychiatrists as a result of these review processes. These problems include unqualified review-ers, lack of avenues for appeal of reviewers’ decisions, disruptions in the therapeutic relation-ship because of the frequency and intensity of reviews, and fears about loss of confidentiality. The author emphasizes the need for setting standards for review organizations that will help overcome these and other problems.
Keywords: utilization management

289. Breslow, R. E., Klinger, B. I., & Erickson, B. J. (1996). Characteristics of managed care patients in psychiatric emergency service. Psychiatric Services, 47, 1259-1261.

Because managed care organizations (MCOs) function as gatekeepers, they should reduce patient reliance on psychiatric emergency services. Among individuals receiving emergency services, those patients in MCOs should be more likely than patients who are not enrolled in managed care to require hospitalization, should require a shorter contact time with the service as a result of preauthorization of hospital care, and should be a more functional group. To test these hypotheses, researchers examined records for 293 patients who visited a psychiatric emergency service, 69 of whom were enrolled in managed care. Contrary to their hypotheses, they found that almost half of the managed care patients visiting the emergency service were not hospitalized, but were referred for outpatient behavioral health services after receiving crisis services. Managed care patients also required more contact time with the serv-ice. Finally, the results showed significant differences between the two groups, with the non-managed- care group having more psychotic and substance abuse disorders, requiring more emergency community interventions, and having more previous psychiatric hospitalizations.
Keywords: outcomes, utilization

290. Burlingame, G. M., Lambert, M. J., Reisinger, C. W., Neff, W. M., & Moiser, J. (1995). Pragmatics of tracking mental health outcomes in a managed care setting. The Journal of Mental Health Administration, 22(3), 226-236.

The authors of this article are a mixture of academic researchers and health program administrators. They discuss logistical and methodological considerations involved in apply-ing outcome monitoring techniques to managed mental health programs for the purposes of accountability and of verifying cost-effectiveness and Continuous Quality Improvement. Topics addressed include selection of representative and meaningful outcome measures, selection of instruments, obstacles to ongoing monitoring systems, the challenges of chang-ing provider behavior toward incorporating outcomes assessment, and the implications for delivery of mental health services.
Keywords: outcomes, performance measurement, quality assurance

291. Burton, W. N., Hoy, D. A., Bonin, R. L., & Gladstone, L. (1989). Quality and cost-effective management of mental health care. Journal of Occupational Medicine, 31, 363-367.

This article describes a corporation-based comprehensive mental health plan that combines expanded outpatient mental health benefits, an emphasis on prevention and early detection, and psychiatric hospital utilization review. Analysis found that the number of hospitalizations, average length of stay, and costs have decreased significantly compared with figures 12 months before the program was implemented. The authors argue that a managed mental health care plan can simultaneously improve quality of services and be cost-effective.
Keywords: costs, quality assurance

292. Carpinello, S., Felton, C. J., Pease, E. A., DeMasi, M., & Donahue, S. (1998). Designing a system for managing the performance of mental health managed care: An example from New York State’s prepaid mental health plan. The Journal of Behavioral Health Services & Research, 25(3), 269-278.

Across the United States, several States are implementing managed care principles as a way both to contain costs and to improve service effectiveness within the publicly funded mental health system. Research on the outcomes of individuals receiving these services and the impact of managed care on the overall system has been sparse, because most mental health care infor-mation systems have been transaction- and not outcome-oriented. In this paper, the authors provide an in-depth analysis of one example of a managed mental health plan with an out-come- oriented information systemÑthe Prepaid Mental Health Program in New York State. The paper examines the development, implementation, and early experiences with the plan’s performance management system for public sector managed behavioral health. The authors highlight policy, administrative, and financial implications of this basis for quality improve-ment activities and information-reporting products.
Keywords: capitation, information systems, New York, performance measurement, public sector, quality assurance

293. Center for Health Policy Studies (1996). Policy assessment study of managed care and mental health/substance abuse services under health care reform. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA).

This report, written for SAMHSA, is the synthesis of two expert advisory panels representing the mental health/substance abuse (MH/SA) community, raw data collected from managed care organizations, and a review of the available literature. The findings are presented in a ques-tion- and-answer format with substantial utilization and cost data analyzed by different patient categories. The report finds that substantial premium savings are brought about by managed care, but that the effects of managed care on MH/SA services are inconsistent as a result of poor data collection and methodological problems. The authors ultimately recommend that SAMHSA continue its role in promoting standardization of performance measures for MH/SA delivery systems (Appendix E is a catalog of potential performance measures deemed suitable by the authors) to better monitor the effects of managed care penetration on the quality of MH/SA services.
Keywords: costs, outcomes, performance measurement, substance abuse, utilization

294. Dickey, B. (1997). Assessing cost and utilization in managed mental health care in the United States. Health Policy, 41 (Suppl.), S163-S174.

This article examines the preliminary results of experiments with Medicaid managed care. The author presents a brief background of the managed care system and describes some of the early failures of Medicaid waivers and managed care at the State level. Preliminary data on mental health and substance abuse expenditures and patterns of use from the successful Medicaid managed care experience in Massachusetts show cost savings without a significant reduction in quality. The author suggests that future experiments with managed care invest in information systems to better track data, pay more attention to quality-of-care issues, move away from externally imposed utilization review processes, and carve out mental health management.
Keywords: carve-outs, costs, evaluation, Massachusetts, Medicaid, public sector, utilization

295. Essock, S., & Goldman, H. (1997). Outcomes and evaluation: System, program, and clinician level measures. In K. Minkoff & D. Pollack (Eds.), Managed mental health care in the public sector: A survival manual. Amsterdam: Harwood Academic Publishers.

Because managed care systems are concerned with the cost-effectiveness of care, this chapter seeks to address how to evaluate and monitor the "effectiveness" component of the equation, with particular attention to the special obligations involved in services provided through the public sector. The authors address relevant outcome measures at the individual client level, treatment program level, and systems level. They discuss the need for outcome measures to be based directly on changes in patients’ disabilities and areas of functional impairment rather than on indirect measures of structures, processes, or indirect outcomes. Outcome measures are hailed as an essential counterbalance to economic incentives to undertreat and as necessary information for determining fair and reasonable distribution of resources. Methods for data collection and factors involved in deciding which outcome measures to use are discussed as well.
Keywords: performance measurement, public sector

296. Feldman, J. (1999). How will mental health outcomes data be used in private systems? New Directions for Mental Health Services, 71, 103-109.

This article discusses how varied mental health outcomes data are used depending on the par-ties involved and their needs. Different stakeholders favor different variables and attempt to influence payers and provider to produce data useful to them. Stakeholders include employers and other payers, managed care organizations, mental health managers and provider groups, patients and families, and researchers and academics. The author summarizes the data needs of each stakeholder and the ideal variables that each stakeholder desires. The author also con-trasts the ideal data needs with data that are currently being used, addresses conflicts between stakeholder needs, and offers an opinion on the types of studies and measures that would affect quality of care.
Keywords: performance measurement

297. Feldman, S. (1992). Managed mental health services: Ideas and issues. In S. Feldman (Ed.), Managed mental health services (1st ed., pp. 3-26). Springfield, IL: Charles C. Thomas.

This chapter discusses several controversial and unresolved issues in the managed mental health care debate. The author describes the rhetoric of the debate and some of the underlying concerns of critics of managed mental health care. For example, he discusses ways in which concerns about loss of money and autonomy tend to be framed in terms that are more profes-sionally and socially acceptableÑsuch as on "quality of life," "professional standards," and "patient needs." The author identifies common misunderstandings about managed care and argues that done well, managed mental health should be a method to better match the treat-ment to the problem. An effective managed care system should integrate managers, providers, and payers into a system of care that can flexibly respond to the needs of the mental health field. The author believes that a constructive tension between providers and case managers should have a positive impact on the quality of care in the managed system. A case study of U.S. Behavioral Health is used to illustrate his points.
Keywords: quality assurance

298. Garnick, D. W., Hendricks, A. M., & Comstock, C. (1996). Using health insurance claims data to analyze substance abuse charges and utilization. Medical Care Research and Review, 53(3), 350-368.

Over the past decade, many researchers have studied health insurance claims data in an effort to answer questions ranging from the effects of managed care on substance abuse cost to the effectiveness of programs to prevent readmissions. Health insurance claims data sets have several advantages, including multiple years of data, very large databases, and informa-tion on a variety of treatment settings. In this article, the authors present several challenges to utilizing insurance claims data by using illustrations from three large employers to answer questions about costs to employers, utilization of services to treat abuse of specific drugs, and the effects of managed care strategies. They conclude that insurance claims data sets are more suitable for researching some questions (such as tracking changes in employers’ charges) than others (such as studying the use of treatment for specific drugs). They suggest three potential improvements to broaden the application of these data sets to substance abuse research.
Keywords: performance measurement, substance abuse, utilization

299. Giles, T. R. (1991). Managed mental health care and effective psychotherapy: A step in the right direction? Journal of Behavior Therapy and Experimental Psychiatry, 22, 83-86.

The author argues that alternatives to fee-for-service models of care delivery, such as HMOs, not only contain costs but better serve the mental health needs of consumers. Because of capitation, practitioners must demonstrate that their methods result in successful outcomes. The paper presents a brief history of managed mental health care and describes how managed care companies are carefully reviewing the outcome literature to identify effective behavioral and short-term treatment approaches.
Keyword: outcomes

300. Ginsberg, S. (1991). Managed care’s paradoxical effect. International Journal of Partial Hospitalization, 7, 171-177.

The author cautions that managed care companies are paying disproportionate attention to the dollar at the expense of appropriate patient care and argues that these companies should be held accountable for decisions to deny payment for treatment. A particularly effective and cost-efficient form of psychiatric care, the day hospital, is discussed at length. The author concludes that utilization review should be undertaken by appropriately trained mental health professionals and that payers must bear responsibility for the impact of the care that patients receive.
Keywords: utilization management

301. Goldman, W., McCulloch, J., Cuffel, B., Zarin, D. A., Suarez, A., & Burns, B. J. (1998). Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. Psychiatric Services, 49, 477-482.

In the era of HMOs, mental health service models that manage costs as well as services have gained increasing popularity. One such model, hypothesized to reduce costs, is "split treat-ment," where psychiatrists provide pharmacotherapy and less costly mental health specialists provide psychotherapy. In order to study the benefits of split therapy over the model of inte-grated therapy, where a psychiatrist provides both pharmacotherapy and psychotherapy, the researchers examined differences in the utilization patterns of depressed patients from a national managed mental HMO in the two treatment models. The results show that patients receiving integrated treatment not only used significantly fewer outpatient sessions, but also had lower treatment costs than those patients in split treatment. The researchers conclude that integrated treatment is not more costly than split treatment in a managed care network.
Keywords: costs, depression, HMOs, models, outcomes, psychotherapy, utilization

302. Goldman, W., McCulloch, J., & Sturm, R. (1998). Costs and use of mental health services before and after managed care. Health Affairs, 17(2), 40-52.

This paper highlights the successful implementation of a West Coast-based employer’s mental health carve-out that achieved parity for mental health services without increasing costs. The authors track the costs of mental health care for a private employer during a period in which mental health benefits were carved out of the medical plan and managed care was introduced. Before the change, mental health costs had been increasing 30 percent annually; in the first year after the change, costs dropped by more than 40 percent while utilization of mental health services actually increased. The authors attribute the successful mental health carve-out experiment to increased efficiency resulting in reduced probability of an inpatient admission, reduced inpatient length-of-stay, and substantially lower costs per unit of service.
Keywords: carve-outs, costs, performance measurement, utilization

303. Hamilton, J. M. (1988). The role of peer review and quality assurance in changing reimbursement schemes. In D. J. Scherl, J. T. English, & S. S. Sharfstein (Eds.), Prospective payment and psychiatric care (pp. 129-138). Washington, DC: American Psychiatric Association.

This chapter describes the activities of the American Psychiatric Association (APA) in quality assurance, utilization review, and peer review. Medical review has progressed from retrospective to concurrent review. Together with the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), the APA developed a national peer review system for inpatient and outpatient psychiatric treatment. APA has also published several editions of its manual providing models for standards and criteria in peer review. The author provides an overview of the APA’s joint venture with the insurance company Intracorp to provide quality assurance, utilization review, case management, and discharging.
Keywords: quality assurance, utilization management

304. Huskamp, H. A. (1998). How a managed behavioral health care carve-out plan affected spending for episodes of treatment. Psychiatric Services, 49(12), 1559-1562.

Many employers and States are carving out behavioral health services from their health plans in an effort to manage behavioral health costs. But are these efforts successful? This paper provides an in-depth exploration of the impact of carving out behavioral health care on spending for episodes of treatment. The researcher compared spending per episode before and after implementation of the carve-out for episodes of care provided in an inpatient facility, episodes involving both inpatient and outpatient care, and episodes involving only outpatient care. From the results, the implementation of the carve-out resulted in a large decrease in spending per episode across all three episode types, with inpatient care showing the greatest reduction. Those episodes involving a diagnosis of either unipolar depression or substance dependence resulted in particularly large reductions, regardless of treatment type.
Keywords: carve-outs, costs, depression, substance abuse

305. Ingram, B. L., & Chung, R. S. (1997). Client satisfaction data and quality improvement planning in managed mental health care organizations, Health Care Management Review, 22(3), 40-52.

This article examines the principles of total quality management (TQM) used by health care administrators to increase the quality of care. The authors perform a Chi Square Automatic Interaction Detection (CHAID) statistical analysis of client satisfaction survey data from a large, national managed care organization to separate clients into two categories, the "maxi-mally" and the "moderately" satisfied, and develop a predictive model of maximum satisfac-tion. The authors present a methodology for the analysis of client satisfaction surveys, and ultimately, suggest ways in which such surveys can be constructed to improve future analyses.
Keywords: client satisfaction, quality assurance

306. Kane, R. L., Bartlett, J., & Potthoff, S. (1995). Building on empirically based outcomes information system for managed mental health care. Psychiatric Services, 46(5), 459-461.

This article describes how one national managed mental health care corporation, in coopera-tion with the University of Minnesota, has begun to create a clinical management information system. The underlying principles of this system involved data collection at admission to create a baseline, and outcome data collection by telephone after departure. The authors view this system as reliable because it had continuous input from clinicians through its development. The key to the success of the system is its use in clinical practice for the analysis of sound data to support better and more effective clinical decision making.
Keywords: information systems

307. Lazarus, A. (1994). Dumping psychiatric patients in the managed care sector. Hospital and Community Psychiatry, 45, 529-530.

This article provides three examples of what the author describes as patient dumping from the medical sector into the managed psychiatric sector. In each of the cases, the patient was transferred to psychiatric facilities while he or she was still medically unstable; in two of the three cases, the transfer had not been authorized by the managed care company. The author cautions that such inappropriate transfers from medical to psychiatric settings may be a result of fragmented treatment brought on by lack of coordination between medical and psychiatric care, and that efforts to control costs through selective contracting, prospective payment, and carve-outs may exacerbate this trend.
Keywords: quality assurance

308. Leff, H. S., & Woocher, L. S. (1998). Trends in the evaluation of managed mental health care. Harvard Review of Psychiatry, 5(6), 344-347.

This article describes work currently under way to develop a tracking system for evaluation studies of public managed behavioral health care. The evaluation studies cited within the arti-cle fall into three broad categories: State-funded and initiated, federally funded and initiated, and investigator-initiated studies funded by foundations or Federal agencies. The authors ana-lyze five studies, the majority of which compare managed care with fee-for-service systems in terms of service use and cost and consumer outcomes such as health status, symptoms, quality of life, and patient satisfaction.
Keywords: client satisfaction, costs, evaluation, outcomes, public sector, utilization

309. Leon, S. C., Lyons, J. S., Christopher, N. J., & Miller, S. I. (1998). Psychiatric hospital outcomes of dual diagnosis patients under managed care. The American Journal on Addictions, 7(1), 81-86.

Many studies have found that utilization patterns of patients with both mental illness and substance abuse diagnoses (the dually diagnosed) differ from non-substance-abusing patients. This study examines the impact of managed care on the inpatient psychiatric utilization of persons with dual diagnosis. Patients with coexisting substance abuse disorders spent fewer days in the hospital, but experienced higher rates of recidivism, than patients with psychiatric disorders only. Such results suggest that managed care has not had an impact on patterns of psychiatric hospital use by patients with coexisting substance abuse disorders. The authors discuss potential incentives for such utilization patterns for the dually diagnosed and stress the importance of focusing solutions on preventative programs.
Keywords: outcomes, utilization

310. McCarthy, P. R., Gelber, S., & Dugger, D. E. (1993). Outcome measurement to outcome management: The critical step. Administration and Policy in Mental Health, 21, 59-68.

Several strategies for measuring mental health outcomes have been developed, but few mechanisms have been designed to assess the quality of care for use in case management. The author describes a conceptual model to measure quality based on a model developed by Donabedian (1980) that evaluates structure, process, and outcome. A quality/improvement algorithm is described that can be used to assess quality in a single system or to compare systems. These data aid in management functions, such as establishing network standards against which individual providers can be compared in terms of both cost-effectiveness and quality. The authors argue that while implementing a quality-focused outcome is clearly more costly in the short term, it will lead to substantial benefits in the long run for the patient, the managed health provider, and the payer.
Keywords: case management, outcomes, performance measurement

311. Milstein, A., Henderson, M., Berlant, J. L., & Anderson, D. (1994). Evaluating psychiatric and substance abuse case management organizations. In S. A. Shueman, W. G. Troy, & S. L. Mayhugh (Eds.), Managed behavioral health care: An industry perspective (pp. 222-240). Springfield, IL: Charles C. Thomas.

In this chapter, the authors discuss two methods of evaluating mental health and chemical dependency case management organizations: (1) direct evaluation of case management operations, including interviews, observations, and examination of staff work sheets; and (2) evaluation of claims data. The authors offer specific steps that can be used to conduct the evaluations and discuss the rationale for using external evaluators.
Keywords: case management, performance measurement

312. Pallak, M. S., & Cummings, N. A. (1994). Outcomes research in managed behavioral health care: Issues, strategies, and trends. In S. A. Shueman, W. G. Troy, & S. L. Mayhugh (Eds.), Managed behavioral health care: An industry perspective (pp. 205-221). Springfield, IL: Charles C. Thomas.

The authors argue that three factors have led to the interest in clinical outcome research in the behavioral sciences. These are (1) the continuing rise in costs for alcohol/drug abuse and mental health services; (2) the perception within the managed care industry that knowledge about outcomes is valuable marketing information; and (3) the increasing availability of research tools and strategies regarding outcomes. In this chapter, they examine the implica-tions of these factors. They explore the problems that managed care companies face when trying to develop procedures to address effectiveness and discuss new trends in treatment outcome measures.
Keywords: outcomes, trends

313. Pandiani, J. A., Banks, S., & Gauvin, L. (1997). A global measure of access to mental health services for a managed care environment. The Journal of Mental Health Administration, 24(3), 268-277.

This article proposes a quantitative measure of access to mental health services in a managed care environment. The measure, referred to as the access ratio, compares the number of people receiving mental health services to the number of people in need of mental health services in a population. The authors describe the methodology for deriving the measures of need and uti-lization, and then illustrate its use by measuring access to inpatient mental health care in the State of Vermont. The results of this study produced objective quantitative measures of access and identified pattern variations in access that can be used as comparative benchmarks for future work in this area. The authors conclude with a discussion of the role of the appropriate use of the access ratio, and other quantitative measures of system performance, in improving systems of care.
Keywords: performance measurement, public sector, Vermont

314. Pickett, S. A., Lyons, J. S., Polonus, T., Seymour, T., & Miller, S. I. (1995). Factors predicting patients’ satisfaction with managed mental health care. Psychiatric Services, 46(7), 722-723.

In response to concerns about quality of care in managed mental health plans, this study examined patients’ satisfaction with a managed mental health care program using a mail sur-vey. The survey included questions measuring two types of variables: patients’ perception of each element in a service delivery model and patients functioning after treatment. From the results, patients who reported better psychological functioning and who found the managed care staff to be helpful and their therapist skillful and conveniently located were more likely to be satisfied with their services. The authors conclude that managed mental health plans should train mental health professionals in effective service delivery, select providers that are convenient for the patient, and monitor the helpfulness of their staff.
Keywords: client satisfaction, performance measurement

315. Roberts, B. (1996). Quality as the driving force for cost-effective psychiatric managed care. Journal for Healthcare Quality, 18(1), 4-8.

This paper outlines the author’s view of the "megatrends" of economics, politics, and tech-nology influencing contemporary psychiatric treatment. The author compares psychiatric treatment between the conventional fee-for-service paradigm and the "new" managed care paradigm. According to the author, the "new" paradigm emphasizes identification and treat-ment of symptoms rather than the diagnosis of disease according to standard therapy. This article compares the two treatment paradigms through a hypothetical clinical case summary of a depressed individual. The author relates an account of the treatment schedule under both the fee-for-service paradigm and the "new" managed care paradigm in an attempt to show that the managed care paradigm provides more focused, cost-effective treatment for psychiatric services.
Keywords: outcomes

316. Roberts, B. (1998). An evolving continuous quality improvement role for managed care: A behavioral healthcare perspective. Journal for Healthcare Quality, 20(5), 20-23.

The author describes the evolution of continuous quality improvement (CQI) in managed behavioral health care. The author posits that the initial impact of managed care on health care was a result of the sentinel, or Hawthorne, effect. The sentinel effect refers to the impact on quality of knowing that outcomes will be monitored. The author proposes that the posi-tive impact of the sentinel effect has ebbed and suggests new ways to continue the evolution. The author suggests the Clinical Navigator Model, in which the clinician is the "navigator" of each patient’s treatment and this navigation can be improved if the clinician follows a few tasks: (1) Define the clinical destination via a clinical assessment with the patient, based on the desired end-result. (2) Develop the best clinical approach to get the desired end-result. (3) Decide on the most effective mode to get to the end result (i.e., the least restrictive, least intrusive site of care). This model can be used to positively reinforce good outcomes and help continue the evolution of managed behavioral health care.
Keywords: models, outcomes, providers, quality assurance

317. Rodriguez, A. R. (1989). Evolutions in utilization and quality management: A crisis for psychiatric services? General Hospital Psychiatry, 11, 256-263.

Science, social policies, and government funding brought about high-quality mental health services from 1948 to the early 1980s, when payers began implementing strategies to reduce and control the costs of health care. These strategies include benefit redesign and structuring, alternative reimbursement methods, utilization review, and alternative delivery systems. The author contends that managed care programs must ensure quality as well as affordability. He argues that this combination will be difficult to achieve because there is little consensus as to what constitutes effective treatment.
Keywords: quality assurance

318. Rodriguez, A. R. (1992). Management of quality, utilization, and risk. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 83-97). Washington, DC: American Psychiatric Press.

In this chapter, the author discusses critical issues in medical quality management. He describes some of the epidemiological trends in the utilization of mental health services, and the mechanisms that have been instituted to control utilization. The mechanisms discussed include benefit redesign and structuring to provide economic disincentives to seek care, alter-native reimbursement approaches such as prospective payment, alternative delivery systems, and utilization review and management. Finally, the author describes some of the major com-ponents of an effective risk management system. He concludes that more effective manage-ment information systems for health services are needed to avoid arbitrary and/or discrimina-tory apportionment systems.
Keywords: overviews, quality assurance

319. Rohrer, J. E., & Rohland, B. M. (1998). Oversight of managed care for behavioral health services. Journal of Public Health Management Practice, 4(1), 96-100.

This article is concerned with the need for payers to be able to set contract specifications for behavioral health services to help ensure that services are delivered in a way that is accessible, efficient, and effective. To that end, these authors propose staff-per-population ratios, service utilization rates, and outcome data as useful performance measures for monitoring the per-formance of managed care providers and for selecting vendors when new contracts are being planned. The authors review previous literature on quality and access indicators and then put forth their own measures as a more practical set of tools. Finally, they emphasize the impor-tance of consistent monitoring and further comparative research to refine indicators.
Keywords: contracting, performance measurement

320. Savitz, S. A. (1992). Measuring quality of care and quality maintenance. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 143-158). Washington, DC: American Psychiatric Press.

This chapter explores ways of defining, measuring, and improving the quality of care in a managed mental health care environment. The author describes the issues of cost versus qual-ity; discusses methods of assessing quality of medical care, including standards for treatment, tracers, patient satisfaction, and claims review; and describes some problems associated with each. He addresses ways in which organizations can improve quality through problem identi-fication, establishing standards, collecting data, remedial action, and monitoring and follow-up. The author concludes that managed care organizations have structural advantages for providing quality care compared with the independent nature of fee-for-service practice.
Keywords: overviews, quality assurance

321. Schoenbaum, M., Zhang, W., & Sturm, R. (1998). Costs and utilization of substance abuse care in a privately insured population under managed care. Psychiatric Services, 49(12), 1573-1578.

Even with the increasing trend toward carving out behavioral health services, there has been little research on the actual cost and utilization of substance abuse and mental health services. This paper examines 1995 cost and utilization patterns for substance abuse treatment for members of private managed care carve-out behavioral health plans. From their review of claims made in 1995 in 93 behavioral health care plans, the researchers found that approxi-mately 5.2 percent of members used mental health services and 0.3 percent used substance abuse services. Average costs for substance abuse patients were more than twice as high as average costs for mental health patients. This disparity in costs reflected greater rates of use of inpatient and intensive outpatient services for substance abuse treatment. The authors con-clude that substance abuse coverage accounts for a small portion of behavioral health cover-age payments and an even smaller fraction of insurance payments for overall health care.
Keywords: carve-outs, costs, substance abuse, utilization

322. Scholle, S. H., Peele, P. B., Kelleher, K. J., Frank, E., & Kupfer, D. (1999). Satisfaction with managed care among persons with bipolar disorder. Psychiatric Services, 50(6), 751.

In this study, researchers surveyed members of a national voluntary case register of persons with bipolar disorder. To examine the impact of restrictions on care on patient satisfaction with care, they categorized respondents into four groups: self-referral to any mental health provider, self-referral to a restricted provider network, referral through another gatekeeper, and referral through a toll-free number. From the results, those respondents with restricted access to provider networks (85 percent of respondents) were less satisfied with their health plans than those respondents with no restrictions (the first category). The authors conclude that sys-tems of care need to track satisfaction over time, because dissatisfaction influences insurance disenrollment, adherence, fragmentation in care, and treatment rates.
Keywords: client satisfaction, depression

323. Sederer, L. I., & St. Clair, R. L. (1990). Quality assurance and managed mental health care. Psychiatric Clinics of North America, 13, 89-97.

This article discusses the ways in which quality of care for mental health services has tradi-tionally been defined and is currently being modified. The authors describe a new direction in quality assurance, called continuous improvement in care, that moves away from quality "control," with its reliance on surveillance, toward a vision of seeking defects as "treasures." The authors describe many of the forms of managed care and some of the potential problems in reconciling quality, cost, access, and efficiency, and offer suggestions for what can be done.
Keywords: overviews, quality assurance

324. Shueman, S. A., & Troy, W. G. (1994). Quality assurance in managed systems. In S. A. Shueman, W. G. Troy, & S. L. Mayhugh (Eds.), Managed behavioral health care: An industry perspective (pp. 131-148). Springfield, IL: Charles C. Thomas.

The main focus of this chapter is on the design of quality assurance (QA) strategies for man-aged behavioral health care systems. The authors describe the characteristics that an adequate QA program should have. These include a system that reflects the perspectives of key stake-holders; that focuses on multiple aspects of clinical services, case management, and administra-tion; and that uses subjective and objective data and multiple data sources to assess quality. The authors profess to take a relatively traditional QA approach, but one that examines the ways in which the applications of QA have been influenced by more recent approaches to quality, such as total quality management and continuous quality improvement.
Keywords: overviews, quality assurance

325. Shueman, S. A., Troy, W. G., & Mayhugh, S. L. (1994). In Mayhugh, S. L. (Ed.), Managed behavioral health care: An industry perspective. Springfield, IL: Charles C. Thomas.

This book is about, for, and by those in the forefront of the managed behavioral health care movement. Part I lays the groundwork by describing how the economic structure of health care in the 1970s and early 1980s was fertile ground on which to sow a managed care approach. Part II focuses on the roles and responsibilities of the provider in a managed care program. In one particularly useful chapter, the essentials of case management are presented as conducted by one specialized case management organization. Part III describes the history of Federal and State initiatives in managed health care, and part IV concentrates on the important topics of quality assurance and practice guidelines. Part V deals with educational issues. The remainder of the book focuses on issues of interest to researchers and program evaluators in managed behavioral health with interesting chapters on the state of outcomes research, and a basic "how to" on evaluating behavioral case management organizations.
Keyword: overviews

326. Shusterman, A. (1994). Expanding the "Q" word. Managed Care Quarterly, 2, 19-21.

This article presents a broad, multidisciplinary definition of quality that moves beyond the therapeutic relationship between a clinician and a provider. In this article, quality includes accessibility, affordability, positive clinical outcomes, and patient satisfaction. The author argues that only through such a systemic approach to quality can mental health care take its rightful place in the sphere of necessary, affordable, universal health care.
Keywords: quality assurance

327. Smith, G. R. (1996). State of the science of mental health and substance abuse patient outcomes assessment. New Directions for Mental Health Services, 71, 59-67.

This article discusses three areas that summarize the current status of patient outcomes assess-ment. The first area concerns achievements in patient outcomes assessment. Providers, payers, and mental health clinicians are becoming proficient in the science of outcomes assessment. Recent advances in outcomes research have been concentrated in two areas: development of a consensus on outcome domains and development of patient-based assessment scales and indexes. The second area concerns issues of scientific debate. The author discusses five such issues that have implications for the design of outcomes assessment: disorder-specific assess-ment versus generic assessment; sampling versus assessment of an entire population; assess-ment of a tracer condition versus assessment of all disorders; brief assessments versus precise, multidimensional assessments; and assessment logistics: Which method is best? Finally, the author discusses the challenges that must be addressed in order to advance the science of outcomes assessment: understanding consumer preferences for a particular outcomes domain, interpretation and management of assessment results, and development of new assessment technology to enhance the feasibility of implementing outcomes assessment systems.
Keywords: outcomes, performance measurement

328. Smith, J., & Gaumer, G. L. (1992). Evaluation of managed mental health programs. In S. Feldman (Ed.), Managed mental health services (1st ed., pp. 165-200). Springfield, IL: Charles C. Thomas.

Evaluation can provide information that can ensure that managed care programs are effective and are not driven purely by untested assumptions held by providers, consumers, and employers. Assessing what happened, why, and the implications of these changes is diffi-cult. The authors discuss some of the important issues in the evaluation of managed mental health programs and provide guidelines for evaluating programs’ effects. To ensure that the evaluation correctly attributes changes to the intervention, evaluators use methods such as randomization, comparison, and control groups. The authors emphasize the importance of descriptive and baseline data.
Keyword: evaluation

329. Stelovich, S. (1992). Managed care and major mental illness: An overview. In J. Feldman & R. J. Fitzpatrick (Eds.), Managed mental health care: Administrative and clinical issues (1st ed., pp. 249-260). Washington, DC: American Psychiatric Press.

A brief historical overview of mental health service delivery is used to illustrate the challenges in finding new ways to provide appropriate care. The author argues that the locus and poten-tial treatment options for mental illness are extremely limited, and that to improve upon historical failures to provide quality mental health care, we need to reassess both the focus (biological, psychological, and social) and setting (spectrum of services) for mentally ill persons. He argues that alliances between managed care systems and private mental health care organizations may significantly increase the quality, number, and spectrum of services as alternatives to the hospital.
Keywords: overviews, quality assurance

330. Sturm, R., Jackson, C. A., Meredith, L. S., Yip, W., Manning, W. G., Rogers, W. H., & Wells, K. B. (1995). Mental health care utilization in prepaid and fee-for-service plans among depressed patients in medical outcomes study. Health Services Research, 30(2), 320-340.

This study examines the difference in utilization patterns among depressed patients between prepaid and fee-for-service health plans. In particular, the authors explore whether there is adverse selection among patients switching between the two types of insurance plans, what effect switching plans has on utilization of services, and whether utilization differences, switch-ing, and provider specialty are related. From their longitudinal data on depressed patients participating in the Medical Outcomes Study, the researchers found that depressed patients in the prepaid system exhibited 35 to 40 percent fewer mental health visits than similar patients in the fee-for-service system. There was some evidence of adverse selection, with patients switching out of prepaid plans showing higher baseline utilization and patients switching out of fee-for-service plans showing lower utilization. While all patients who switched plans demonstrated a decline in utilization, there was no increase in utilization after the switch. The authors conclude that there is an interruption in care for patients switching between plans.
Keywords: depression, outcomes, utilization

331. Thompson, J. W., Burns, B. J., Goldman, H. H., & Smith, J. (1992). Initial level of care and clinical status in a managed mental health program. Hospital and Community Psychiatry, 43, 599-603.

This study uses indirect measures to examine the quality of care of a managed mental health care demonstration project, using data from 9,055 adult psychiatric intakes. The relationship between clinical status and level of care was the indirect measure used to assess quality. The study found a 50 percent decrease in the use of inpatient care in all clinical conditions (mild to severe) under the managed care system. The study also found that the use of detoxification and outpatient services doubled. The diversion of patients to outpatient care was not related to condition but to a policy decision. The authors conclude that data must be case-oriented, rating scales must be systematized, and measures of treatment outcome are needed in order to better assess the quality of these programs.
Keywords: performance measurement, quality assurance, utilization

332. Wells, K. B., Astrachan, B. M., Tischler, G. L., & Unutzer, J. (1995). Issues and approaches in evaluating managed mental health care. The Milbank Quarterly, 73(1), 57-75.

The purpose of this article is to discuss methodological considerations involved in conducting research into the performance of managed care organizations (MCOs) with respect to access, quality, and outcomes. The article begins by defining and describing different types of MCOs and explaining some of their methods for achieving cost savings. These methods include pre-certification, the use of gatekeepers and case management strategies, provider selection, and clinical guidelines and protocols. With regard to the evaluation of mental health services deliv-ered by MCOs, these authors discuss challenges and obstacles to research, such as issues of confidentiality, problems with data sources, and feasibility of developing and implementing more complex research protocols in the fast-paced and profit-driven environment of private MCOs. In describing approaches to managed care research, these authors address differences in priorities and obstacles for internal and external evaluation studies, and for studies that facilitate industry purposes versus studies that are of interest from a societal perspective. Sample data from a variety of evaluation studies are presented to illustrate the discussion.
Keywords: evaluation, performance measurement

333. Westermeyer, J. (1991). Problems with managed psychiatric care without a psychiatrist-manager. Hospital and Community Psychiatry, 42, 1221-1224.

The author uses seven case studies to illustrate that managed psychiatric care in which a nonpsychiatrist directs care can harm patients with severe psychiatric illness. In a review of these cases, the author found indication of the following problems: infrequent and inconsistent psychotherapy, failure to recommend standard therapies, poor recordkeeping, and inappropri-ate use and monitoring of hospitalization and medications. He suggests ways in which higher quality mental health care can be administered within a managed context. These include more consistent monitoring of quality of outpatient care, use of fourth-party audit organizations, and increased use of peer review.
Keywords: quality assurance

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This page was last reviewed by Dr Greg Mulhauser, Thursday, 14 October 2021.