xxAACP Newsletter, Volume 12,
Number 2, Spring 1998
American Association of Community Psychiatrists
Position Paper on
Position Paper on
Standards of Quality Management in Implementing Public Sector Managed Care Systems Introduction
The introduction of managed care into mental health delivery systems has represented a dramatic transformation of the organization and payment methodology for mental health services. In the private sector, managed care initiatives have offered the promise of controlling escalating costs without compromising quality. The perception of success in the private sector has led to increasing pressure to develop managed care initiatives in the public sector.The emergence of public sector managed care (PSMC) offers the opportunity for creativity and flexibility in program and system design, as well as the potential for more efficient utilization of scarce public funds. At the same time, PSMC may pose great dangers. Unlike the private sector, public mental health and substance abuse expenditures, while at times inefficient, have never been excessive. Unfortunately, public payers, struggling with diminishing budgets, may view PSMC as an opportunity to reduce already inadequate funding without sufficient guarantees of quality. This can seriously jeopardize clinical outcomes for public patients, who are relatively powerless to voice their concerns or have much influence on policy or funding decisions. This can be compounded by the willingness of managed care organizations, (MCOs), seeking new markets, to accept and implement underfunded contracts. In some states and regions these negative outcomes have already occurred or are beginning to be realized.
The AACP supports the development of PSMC, but only as a method for more efficient utilization of scarce resources to improve the quality and outcome of care. However, currently available methodologies for measuring performance of managed behavioral health systems (e.g. PSMC, HEDIS, JCAHO-ORYX) are woefully inadequate. We believe more comprehensive quality management systems are a necessity.
We have carefully examined numerous PSMC initiatives and have identified key variables that contribute to or detract from quality outcomes. Based on this analysis, we have developed the following standards for quality management in PSMC systems. These standards are not simply statements of principle. They are intended to be measurable indicators by which any individual or entity can determine whether an adequate structure for quality management is in place prior to the implementation of any PSMC contract.
PSMC Quality Standards
2. Measurable Indicators. All PSMC initiatives must define a set of measurable quality indicators to define program objectives.
3. Comprehensive Quality Monitoring. These indicators must cover, at minimum, the following areas that relate to the structure, process, and outcome of care in the PSMC system:
- Access to Care:
Size, availability, and composition of provider network
Caseload sizes and waiting lists
Availability of crisis services
- Continuity of Care:
Preservation of existing community treatment relationships and support systems
Availability of case management services for high-risk, high-utilizer children and adults
Linkages between outpatient and inpatient services
- Comprehensivness and Appropriateness of Care:
Comprehensive continuity of services for all ages, diagnoses, and levels of complexity
Flexible benefit design to encourage utilization of alternative service models including a comprehensive array of psychotherapeutic and psychopharmacology modalities
Treatment in the least restrictive and most therapeutic setting
Adequacy of formulary and laboratory services and resources
- Responsiveness of Care:
Documentation of consumer and family involvement in treatment planning
Adherence to appropriate consumer rights policies
Monitoring use of restraint, seclusion, and involuntary treatment
Cultural competence in services as defined by ethnically and culturally specific indicators
- Integration of Care:
Mental health and addictions services
Mental health and primary care services, including health promotion and disease prevention
Child/family mental health and child/family social and educational services
Mental health and community support and rehabilitation services, including psychosocial rehabilitation, housing, and vocational supports
Mental health and corrections services
- Outcomes of Care:
Measure of clinical outcomes, including quality of life
Relapse and rehospitalization rates
Adverse incidents monitoring
Consumer and family satisfaction surveys
4. Adherence to National Standards. The program design and quality measures must reference one or more existing standards for PSMC and clarify and demonstrate adherence to those standards.
5. Inclusive Governance. All systems must have inclusive governance, through a structured and empowered accountability system in the form of an oversight board or similar entity, with representation of consumers, families, providers, and other advocacy groups.
6. Empowered Quality Monitoring. The oversight group should have the authority to approve the quality standards for monitoring quality data and to require corrective action to address identified quality deficiencies.
7. Grievance and Appeals Process. There must be a well-defined grievance and appeals process which can promptly and effectively evaluate adverse incidents and resolve disagreements that occur between the managed care organizations and consumers and/or providers. There must be an independent ombudsman's office to act as final arbiter of appeals, as only an independent agency can equitably rule on quality care issues without conflict of interest.
8. Effective Management Information Systems. The information system should effectively capture clinical data to utilize for quality and outcomes monitoring, while preserving client confidentiality.
9. Independent Program Evaluation. In addition to the internal QM system, there should be a funded independent program evaluator to conduct an external audit of the program at least annually in order to ensure the likelihood that the PSMC system change is successfully maintaining or improving quality.
References are available upon request of Editor, Community Psychiatry, at sowers@connecttime.net or FAX 412-622-6756.
Web Editor's Note, June 1, 2002:
An updated version of this position paper,including the references, can
be found at
http://www.wpic.pitt.edu/aacp/finds/quality.html.
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