Quality measurement and accountability for substance abuse and mental health services in managed care organizations

OBJECTIVES: To analyze managed care organizations' (MCOs') use of behavioral health quality management activities using nationally representative survey data. MATERIALS AND METHODS: The primary data source is the Brandeis Survey on Alcohol, Drug Abuse, and Mental Health Services in MCOs. Using a sampling strategy designed for national estimates, we surveyed 434 MCOs in 60 market areas (response rate = 92%) regarding their commercial products' behavioral health services in 1999. Of these, 417 MCOs reported clinically oriented information for 752 products. We investigated the use of four behavioral health quality management activities: patient satisfaction surveys, clinical outcomes assessment, performance indicators, and practice guidelines. chi tests and logistic regression were used to determine effects of product type (HMO, PPO, point-of-service) and behavioral health contracting arrangement (specialty contract, comprehensive contract including general medical and behavioral health, internal provision). RESULTS: Three-quarters of products used patient satisfaction surveys (70.1%), performance indicators (72.7%), and practice guidelines (73.8%) for behavioral health. Under half (48.9%) assessed clinical outcomes. HMO products were most likely, and PPOs least likely, to conduct activities. Quality activities were significantly more common among specialty-contract products. Logistic regression showed significant negative effects on quality activity use for PPO and POS products compared with HMOs. For clinical outcomes, specialty- and comprehensive-contract arrangements had significant positive effects. There were interactions between product type and contract arrangement. CONCLUSIONS: Most commercial managed care products use patient satisfaction surveys, performance indicators, and practice guidelines for behavioral health, whereas clinical outcomes assessment is less common. Product type and contracting arrangements significantly affect use of these activities.     

Identification and treatment of mental and substance use conditions: health plans strategies

BACKGROUND: Mental health and substance use conditions are under-recognized and under-treated. Private health plans may be able to affect the extent of screening and, thus, identification of enrollees who need treatment. OBJECTIVES: The goals of this study were to determine strategies used by health plans to identify mental health and substance use conditions; and describe the characteristics of health plans associated with use of these strategies. METHODS: In 2003, we conducted a nationally representative survey of private health plans regarding behavioral health services. A total of 368 health plans (83% response rate) provided information about their managed care products: health maintenance organization (HMO), point-of-service (POS), or preferred provider organization (PPO) products (812 in total). MEASURES: We asked whether plans verify primary care providers' screening for mental health or substance use conditions, screen outside of primary care, and distribute practice guidelines. We characterized each product in terms of "carve-out" to a specialty behavioral health vendor, tax status, and region and market area population. RESULTS: Thirty-four percent of products verify primary care providers' screening for mental health, but only 8% verify alcohol or drug screening. Outside of primary care, 31% conduct screening through the mail, phone, or internet. Depression guidelines are distributed to primary care providers by 78% of managed care products: alcohol or drug guidelines are distributed by 33%. In multivariate analyses, specialty contracting was positively associated, and PPO product type was negatively associated with these strategies. CONCLUSIONS: Most health plans use multiple strategies to improve identification of behavioral health conditions, but use of such strategies was greater for mental health than for substance use conditions.     

Providing more through less: current methods of retraction in SIMIS and NOTES cholecystectomy

Background

As the field of minimally invasive surgery continues to develop, surgeons are confronted with the challenge of performing conventional laparoscopic surgeries through fewer incisions while maintaining the same degree of safety and surgical efficiency. Most of these methods involve elimination of the ports previously designated for retraction. As a result, minimally invasive surgeons have been forced to develop minimally invasive and ingenious methods for providing adequate retraction for these procedures. Herein we present our experience using endoloops and internal retractors to provide retraction during Single Incision Minimally Invasive Surgery (SIMIS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) cholecystectomy. We also present a review of the alternative retraction methods currently being employed for these surgeries.

Methods

SIMIS was performed on 20 patients and NOTES was performed on 5 patients at our institution. Endoloops or internal retractors were used to provide retraction for all SIMIS procedures. Internal retractors provided retraction for all NOTES procedures.

Results

Successful cholecystectomy was accomplished in all cases. One SIMIS surgery required conversion to standard laparoscopy due to complex anatomy. There were no intraoperative complications. Although adequate retraction was accomplished in all cases, the internal retractors were found to provide superior and more versatile retraction compared to that of endoloops.

Conclusion

Adequate retraction greatly simplifies SIMIS and NOTES surgery. Endograb internal retractors were easy to use and were found to provide optimal retraction and exposure during these procedures without complications.     

The impact of proton-pump inhibitors on intraperitoneal sepsis: a word of caution for transgastric NOTES procedures

Background  

During transgastric natural orifice transluminal endoscopic surgery (NOTES), there is an iatrogenic perforation of the gastric wall with leakage of gastric contents into the peritoneal cavity. The aim of this study is to determine the effect of proton-pump inhibitors (PPI) and alterations of gastric pH on infection during transgastric surgery.     

Advancing performance measures for use of medications in substance abuse treatment

Performance measures have the potential to drive high-quality health care. However, technical and policy challenges exist in developing and implementing measures to assess substance use disorder (SUD) pharmacotherapy. Of critical importance in advancing performance measures for use of SUD pharmacotherapy is the recognition that different measurement approaches may be needed in the public and private sectors and will be determined by the availability of different data collection and monitoring systems. In 2009, the Washington Circle convened a panel of nationally recognized insurers, purchasers, providers, policy makers, and researchers to address this topic. The charge of the panel was to identify opportunities and challenges in advancing use of SUD pharmacotherapy performance measures across a range of systems. This article summarizes those findings by identifying a number of critical themes related to advancing SUD pharmacotherapy performance measures, highlighting examples from the field, and recommending actions for policy makers.     

Tumor size is associated with the systemic inflammatory response but not survival in patients with primary operable colorectal cancer

AIM: To examine the relationship between tumor diameter, C-reactive protein concentrations and survival in patients undergoing surgery for colorectal cancer. METHOD: Tumor diameter and pathological characteristics of the resected specimen were assessed in 227 patients. Circulating concentrations of C-reactive protein were measured prior to surgery. RESULTS: Ninety-six patients had an elevated C-reactive protein concentration (>10 mg/L) prior to surgery. Tumor size was associated with an elevated C-reactive protein concentration (P < 0.001). C-reactive protein concentrations (P < 0.001) were associated with poorer cancer-specific survival. CONCLUSION: Prior to surgery, the maximal tumor diameter is associated with an elevated preoperative C-reactive protein concentration but not survival in patients with primary operable colorectal cancer.     

Health Plan Requirements for Mental Health and Substance Use Screening in Primary Care

BACKGROUND Screening for substance abuse and mental health in primary care can improve detection. One way to advance screening is for health plans to require it. OBJECTIVES We developed national estimates of the prevalence and type of mental and substance-use condition screening health plans require of primary care practitioners. DESIGN In 1999 (N = 434, response rate = 92%) and 2003 (N = 368, response rate = 83%), we conducted a nationally representative health plan survey regarding alcohol, drug, and mental health services, including screening requirements. PARTICIPANTS Health plans reported on screening requirements of their top three private insurance products. Products were categorized by type (HMO, POS, or PPO), behavioral health contracting arrangements, tax status, market area population, and region. MEASUREMENTS We asked whether primary care practitioners are required to use a general health screening questionnaire (including mental health, alcohol, or drugs items) and/or a screening questionnaire focused on mental health, alcohol, or drug problems. RESULTS By 2003, 34% of products had any behavioral health screening requirements. Although there was no increase from 1999 to 2003 in requirements for any kind of behavioral health screening, requirements for using a standard screening instrument declined for mental health but increased for alcohol and drug screening. PPOs showed the largest increase in prevalence of behavioral health screening requirements. Products contracting with managed behavioral health organizations were more likely to require screening. CONCLUSIONS Most products do not require behavioral health screening in primary care. More screening could help to improve identification of behavioral health conditions, a first step towards effective treatment.     

Integrated Employee Assistance Program/Managed Behavioral Health Care Benefits: Relationship with Access and Client Characteristics

This study examined service user characteristics and determinants of access for enrollees in integrated EAP/behavioral health versus standard managed behavioral health care plans. A national managed behavioral health care organization’s claims data from 2004 were used. Integrated plan service users were more likely to be employees rather than dependents, and to be diagnosed with adjustment disorder. Logistic regression analyses found greater likelihood in integrated plans of accessing behavioral health services (OR 1.20, CI 1.17–1.24), and substance abuse services specifically (OR 1.23, CI 1.06–1.43). Results are consistent with the concept that EAP benefits may increase access and address problems earlier.