Principles for Systems of Managed Care

The Substance Abuse and Mental Health Services Administration's Center for Mental Health Services (CMHS) provides national leadership for improving the quality and availability of treatment and prevention services for mental illness, particularly with respect to adults with serious mental illness and children with serious emotional disturbances. As part of its mission, CMHS promotes policies for managed care systems by:

• promoting policies and standards for managed care systems that reflect equity and parity in the treatment and rehabilitation of persons with mental health care needs with other health care needs;
• fostering the development of linkages and partnerships among and between critical stakeholders such as consumers, family members, advocates, Federal agencies, States, counties and local communities, native American tribes, purchasers, managed care organizations, and providers working within managed care systems;
• providing training and technical assistance to all stakeholders in the mental health field in key policy areas for managed care systems;
• collaborating with managed care systems to encourage the provision of high quality and effective clinical and support services to promote a high quality of life for persons with mental health care needs; and
• promoting strategies for expanding health insurance coverage for individuals who are under/uninsured.

CMHS recognizes that changes in health care financing and organization make it imperative that all stakeholders work collaboratively in an effort to deliver accessible, appropriate, comprehensive, culturally competent, cost-effective services of the highest quality.

Policies and practices should address the concerns of all stakeholders in the system and ultimately be responsive to the rights and needs of the individual receiving the service.

Responsibility for the public health and well being of our citizens should be shared. To foster this goal, the following principles are offered to all stakeholders as public and private sector system integration occurs.

Quality of Care

Managed care systems should:

• treat all persons with respect and dignity;
• be based on "best practices," model programs, innovation, and continuous quality improvement;
• develop delivery and data collection systems to address the unique developmental needs of children and their families;
• ensure that services are tailored to individual needs and preferences, provided in the least restrictive and most natural setting possible and built on the strengths of the consumer and family;
• establish credential verification programs, assess critical provider skills and competencies, and provide necessary training to facilitate human resource development;
• provide mechanisms for resolution of provider disputes;
• ensure that services for adults directly include a continuum of care consisting of, but not limited to, a comprehensive array of flexible community living supports including prevention, treatment, rehabilitation, support, psychiatric rehabilitation, intensive case management, residential treatment, crisis, and self-help services and also provide effective linkages to other health and social services;
• ensure that services for children directly include a "wrap around" approach consisting of, but not limited to, flexible, individualized, strengths-based, family-driven services incorporating respite care, case management, day treatment, recreational support, and other non-traditional home and community-based services and also provide effective linkages to other health and social services; and
• incorporate targeted prevention activities, especially at key points of life transitions.

Consumer Participation and Rights

Managed care systems should:

• meaningfully involve consumers and family members in the planning, development, delivery, evaluation, research and policy formation of managed care systems including the determination of "medically necessary" services;
• respect consumer choice of services, providers and treatment and assure consumer informed voluntary consent. Individual treatment plans should be based on the preferences and needs of consumers and families with children;
• ensure that consumers receive necessary legal and ethical protections and services;
• provide education to consumers and family members on their rights and responsibilities;
• establish grievance, mediation, arbitration, and appeals procedures to resolve consumer disputes in a timely manner. Ombudsman services should be provided. Necessary services should continue pending dispute resolution;
• support consumer rights and empowerment by providing education about, and access to, local self-help groups and protection and advocacy organizations; and
• ensure that confidentiality and privacy of consumer health care information is protected at all times, particularly as electronic information systems develop and expand. Release of specific information should occur only with a signed release from either the recipient of services or their legal guardian/representative.

Accessibility

Managed care systems should:

• ensure that services are culturally and linguistically appropriate, available, acceptable, and accessible (including geographically) to all individuals, with particular attention to vulnerable populations;
• provide education about mental health benefits and ways to access emergent, acute and routine care;
• provide services for individuals with pre-existing illness;
• work with provider networks that include community providers experienced in working with vulnerable populations;
• make available necessary specialized services required by participants that are not available through managed care system provider networks; and
• ensure continuity of care during transition from the current system to managed care environments and among different managed care systems as contracts change.

Affordability

Managed care systems should:

• provide affordable interventions at all levels of the continuum of care to reduce the prevalence and/or severity of mental illness and resulting disability through early prevention and identification of risk factors;
• ensure reasonableness of out-of-pocket costs and provide full access to critical services, especially for indigent populations; and
• provide appropriate mechanisms for consumers who want to seek care from providers who may be outside the established networks. Linkages and Integration

Linkages and Integration

Managed care systems should:

• coordinate with primary health care and substance abuse systems;
• utilize interagency collaborations with human services agencies such as public health, social service, child welfare, education, juvenile justice, criminal justice and long-term care systems; and
• assure linkage to critical services such as employment supports, housing, transportation, self-care and mutual support organizations, education and training opportunities, and rehabilitation service.

Accountability

Managed care systems should:

• engage stakeholders in developing and assessing quality assurance standards, and in incorporating performance, outcome (e.g., recovery and community integration) and consumer satisfaction measures to evaluate plan performance over the long-term, including measures of access, appropriateness, quality, outcome, and cost effectiveness;
• employ various evaluation methods including report cards and consumer satisfaction surveys and make the information available for further analysis;
• collect, analyze and publicly disseminate reliable information to foster system accountability and quality improvement; and
• develop information systems at the provider and managed care network levels collecting data on demographics, service utilization, revenues, costs, service outcomes, service provider performance, consumer satisfaction, and quality of life.

CMHS welcomes input and suggestions for subsequent updates of these principles

For more information, call SAMHSA's National Mental Health Information Center at 1-800- 789-CMHS (2647)

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