A framework for assessing the effectiveness, efficiency, and equity of behavioral healthcare.
OBJECTIVE: To evaluate the effectiveness, efficiency, and equity of behavioral healthcare and to guide an assessment of the current state of the art of behavioral health-oriented health services research. STUDY DESIGN: The framework is grounded in previous conceptual work by the authors in defining a prevention- and outcomes-oriented continuum of healthcare and in identifying and integrating the concepts and methods of health services research and policy analysis for assessing healthcare system performance. PATIENTS AND METHODS: The defining assumptions are that (1) the denominator for behavioral healthcare services must encompass a look at the population, not just the patients, who manifest behavioral health risks; and (2) the delivery system to address these needs must extend beyond acute, treatment-oriented services to include both primary prevention and aftercare services for chronic relapsing conditions. RESULTS: Current policy and practice in behavioral healthcare reveal the absence of a comprehensive, coordinated continuum of care; substantial variation in policy and financial incentives to encourage such development; and poorly defined or articulated outcome goals and objectives. The current state of the art of research in this area reflects considerable imprecision in conceptualizing and measuring the effectiveness, efficiency, and equity criteria. Further, these 3 criteria have not been examined together in evaluating system performance. CONCLUSIONS: The first era of behavioral healthcare focused on cost savings in managed care alternatives; the second is focusing on quality and outcomes; a third must consider the issues of equity and access to behavioral healthcare, especially for the most seriously ill and vulnerable, in an increasingly managed care-dominated public and private policy environment. (+info)
Use of performance standards in behavioral health carve-out contracts among Fortune 500 firms.
OBJECTIVE: To determine the prevalence and nature of performance standards in specialty managed behavioral healthcare contracts among Fortune 500 companies. STUDY DESIGN: This was a cross-sectional survey of all companies listed on the Fortune 500 during 1994, 1995, or both. METHODS: From April 1997 to May 1998 we conducted a mailed survey with phone follow-up. Of the 68% of firms that responded, over one third reported carve-out contracts. The survey focused on whether companies had behavioral health carve-out contracts with specialty vendors and characteristics of these contracts, including the use of performance standards. RESULTS: More than three quarters of the Fortune 500 companies reporting specialty behavioral healthcare contracts used at least one performance standard. Most common were administrative standards (70.2%) and customer service standards (69.4%). About half of the companies used quality standards, whereas only a third used provider-related standards. Most (58.8%) companies using performance standards also specified financial consequences. Larger Fortune 500 firms were significantly more likely to use performance standards. Risk contracts and contracts that included all covered employees were also more likely to include some categories of standards. CONCLUSIONS: Administrative and customer service standards may be most common because companies find it easier to specify those standards, especially compared with clinical quality measures. To the extent that employers want to obtain the most value from their behavioral healthcare purchasing, we expect that more will begin to adopt quality standards in their contracts, especially as performance measures become more refined. Reliance on accreditation, however, is an alternative approach for employers. (+info)
Community effects on access to behavioral health care.
OBJECTIVE: To explore the effects of community-level factors on access to any behavioral health care and specialty behavioral health care. DATA: Healthcare for Communities household survey data, merged to supplemental data from the 1990 Census Area Resource File, 1995 U.S. Census Bureau Small Area Estimates, and 1994 HMO enrollment data. STUDY DESIGN: We use a random intercept model to estimate the influences of community-level factors on access to any outpatient care, any behavioral health care conditional on having received outpatient care, and any specialty behavioral health care conditional on having received behavioral health care. DATA COLLECTION: HCC data were collected in 1997 from about 10,000 households nationwide but clustered in 60 sites. PRINCIPAL FINDINGS: Individuals in areas with greater HMO presence have better overall access to care, which in turn affects access to behavioral health care; individuals in poorer communities have less access to specialty care compared to individuals in wealthier communities. CONCLUSIONS: Our findings of lower access to specialty care among those in poor communities raises concerns about the appropriateness and quality of the behavioral health care they are receiving. More generally, the findings suggest the importance of considering the current status and expected evolution of HMO penetration and the income level in a community when devising health care policy. (+info)
The role of behavioral and psychosocial science in reducing cancer morbidity and mortality.
Behavioral and psychosocial science has the potential to contribute much to the overall effort to reduce cancer morbidity and mortality and to improve the quality of life for cancer patients and their families. However, for a variety of reasons, including a lack of sustained funding for research and training and a lack of confidence by some in the potential payoff for investments in the area, this potential has not only not been realized but also not been adequately explored. A special subcommittee of "The March" Research Task Force studied research in this area and issued a report making several recommendations for future funding for psychosocial and behavioral research in cancer. This article reports those recommendations and the reasons the committee supported them. (+info)
Setting rates for Medicaid managed behavioral health care: lessons learned.
This paper reviews Tennessee's experience setting, monitoring, and updating capitation rates for Medicaid managed behavioral health care, and draws lessons from those experiences for other states. Our review of assumptions about four components of Tennessee's rate-setting process--data, benefit design, savings expectations, and processes for monitoring and updating rates--suggests that the initial rate established by Tennessee was inadequate, and its inadequacy resulted primarily from the way available information was used to set the rate, rather than from the method of rate setting selected. Tennessee's experiences illustrate how difficult rate setting is and illuminate several key lessons about the rate-setting process. (+info)
Managed behavioral health care: an instrument to characterize critical elements of public sector programs.
OBJECTIVE: To develop an instrument to characterize public sector managed behavioral health care arrangements to capture key differences between managed and "unmanaged" care and among managed care arrangements. STUDY DESIGN: The instrument was developed by a multi-institutional group of collaborators with participation of an expert panel. Included are six domains predicted to have an impact on access, service utilization, costs, and quality. The domains are: characteristics of the managed care plan, enrolled population, benefit design, payment and risk arrangements, composition of provider networks, and accountability. Data are collected at three levels: managed care organization, subcontractor, and network of service providers. DATA COLLECTION METHODS: Data are collected through contract abstraction and key informant interviews. A multilevel coding scheme is used to organize the data into a matrix along key domains, which is then reviewed and verified by the key informants. PRINCIPAL FINDINGS: This instrument can usefully differentiate between and among Medicaid fee-for-service programs and Medicaid managed care plans along key domains of interest. Beyond documenting basic features of the plans and providing contextual information, these data will support the refinement and testing of hypotheses about the impact of public sector managed care on access, quality, costs, and outcomes of care. CONCLUSIONS: If managed behavioral health care research is to advance beyond simple case study comparisons, a well-conceptualized set of instruments is necessary. (+info)
Health psychology: a new form of psychotherapy?
Psychotherapy in its traditional form is being challenged due to managed care pressures. Psychotherapy using the model of health psychology can adapt well in a managed care environment. Differences between traditional psychotherapy and the psychotherapeutic approach of health psychology are discussed in this article, with a focus on an overview of health psychology and its applications to primary care, and the concept of single-session therapy. A case example of a sample treatment emphasizing the model of brief health psychology treatment is illustrated. (+info)
Quality of life theory III. Maslow revisited.
In 1962, Abraham Maslow published his book Towards a Psychology of Being, and established a theory of quality of life, which still is considered a consistent theory of quality of life. Maslow based his theory for development towards happiness and true being on the concept of human needs. He described his approach as an existentialistic psychology of self-actualization, based on personal growth. When we take more responsibility for our own life, we take more of the good qualities that we have into use, and we become more free, powerful, happy, and healthy. It seems that Maslow's concept of self-actualization can play an important role in modern medicine. As most chronic diseases often do not disappear in spite of the best biomedical treatments, it might be that the real change our patients have for betterment is understanding and living the noble path of personal development. The hidden potential for improving life really lies in helping the patient to acknowledge that his or her lust for life, his or her needs, and his or her wish to contribute, is really deep down in human existence one and the same. But you will only find this hidden meaning of life if you scrutinize your own life and existence closely enough, to come to know your innermost self. (+info)