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and it exempts small businesses with 2 to 50 employees. The compromise version was passed as part of the annual appropriations bill for the Departments of Housing and Urban Development and Veterans Affairs in October 1996 and additional parity proposals are likely in the future.

In 1993, the Institute of Medicine went on record supporting universal access to insurance and health care (IOM, 1993, p. 7) by saying, “All or virtually all persons—whether employed or not, whether ill or well, whether old or young —must participate in a health benefits plan.” The present committee agrees with this goal and recognizes that the absence of a national strategy for universal coverage means that the responsibility lies with the states.

The committee therefore adopted a broad perspective on access to mental health and substance abuse treatment and prevention services. The committee defines access as the extent to which those in need of mental health and substance abuse care receive services that are appropriate to the severity of their illness and the complexity of their needs. Too often indicators of access reflect merely the availability of services or the delivery of any service rather than the delivery of services that respond effectively to the needs. In fact, an analysis of the measures used to assess access suggests that they often merely reflect prompt attention rather than the amount and level of care delivered.

MEASURES OF ACCESS

Managed behavioral health care organizations, purchasers, and accreditation organizations are using a variety of measures of access. Box 5.1 compares some of the existing measures.

A survey of performance indicators used in mental health facilities, community mental health centers, behavioral group practices, and managed care organizations examined 11 measures of access and assessed current use, appropriateness of use, perceived validity, and measurement feasibility (IBH, 1995). The assessment found that the organizations were most likely to monitor access using utilization and penetration rates: (1) days and number of visits per 1,000 population, (2) average length of stay, and (3) number of sessions per episode of care. More than 90 percent of the respondents rated measures of patient satisfaction with access, waiting time for emergency visits, and geographical convenience as useful measures. Patient satisfaction, however, was perceived as the least valid measure, and only 55 percent of the respondents monitored geographical convenience; waiting time was rated as useful by 70 percent of the respondents. Finally, managed care organizations rated telephone access highly. The overall impression is that relatively little attention has been given to the development of systems and measures to monitor access.

Analysis of the access standards proposed for the National Committee on Quality Assurance's Health Plan Employer Data and Information Set version 3.0 (HEDIS 3.0), and of those currently used by Digital Equipment Corporation and



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