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the American Managed Behavioral Healthcare Association (AMBHA) confirm that initial impression. Prompt attention is measured and assessed more often than the fit between the service provided and the level of need. HEDIS 3.0, for example, only requires monitoring of appointment waiting time, telephone access time, and the number of mental health and chemical dependency providers available to plan members (NCQA, 1996). Digital Equipment Corporation's (1995) standards reflect HEDIS 3.0 but specify the performance expected. AMBHA's (1995) Performance-Based Measures for Managed Behavioral Healthcare (PERMS 1.0), perhaps because the AMBHA membership specializes in the management of mental health and substance abuse services, disaggregate penetration and utilization rates by age and diagnostic category but do not assess the overall need for services and whether the services are appropriate for the needs. Thus, the current measures of access used in commercial arenas appear to be insufficient for monitoring access in a more comprehensive fashion.

The National Association of County Behavioral Health Directors recommended a broader set of access measures in their review of performance outcome indicators (The Evaluation Center@HSRI, 1996). Their measures reflect the broader mission of public systems of care and include cultural competencies training for staff, consumer reports of language and cultural barriers to using services, cultural similarities between staff and consumers, geographic access to care, and consumer reports that services were accessible and convenient, in addition to measures of waiting time. These measures of access begin to monitor some of the more subtle barriers to care and should be more widely disseminated and adopted. There is still no information, however, on the level of need for care in the enrollee population and the degree to which the need is being met.

NEED AND ACCESS

The committee believes that purchasers and plan managers should be encouraged to expand their monitoring of access. The indicators promoted for use in county behavioral health programs illustrate strategies for monitoring more subtle influences on access. Population measures of need, however, must still be developed and integrated into the access monitoring systems. A managed care program, for example, might be satisfied with a penetration rate of 10 percent for mental health and substance abuse services. If information on need, however, suggested that 20 percent of plan members were in need of services, a 10 percent penetration rate would be less satisfactory.

Population-based measures of health status and needs assessment, in fact, are major components in the development of effective integrated systems of care (Shortell et al., 1994). Close linkages are required with public health and social service systems so that health status can be assessed and monitored. Managed systems of care must improve their ability to assess the needs of their enrollees and collect primary data on the populations that they serve, especially those at great-



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