and the use of performance measurement systems. At the same time, it has considered complementary strategies that can aid in consumer protection and quality improvement, such as consumer choice of health plans and better integration of research and practice.

This comprehensive approach is required, in the committee's view, given the interrelated, significant, and complex changes that are under way and the vulnerability of individuals who suffer from serious mental illness and addictions to alcohol and other drugs. The committee believes that there is increasing evidence that treatment for mental health and substance abuse problems is effective and that its effectiveness is generally comparable to that of treatment provided in other areas of medicine. The committee also believes that robust steps to address consumer protection and quality improvements are essential, particularly through improved accreditation and performance measurement systems.

This chapter sets out the committee's recommendations in 12 areas. Each set of recommendations is preceded by the findings that led the committee to make the recommendations. In many cases, the findings build on cross-cutting themes from testimony, research, and the committee's deliberations.

• Historically, the structure and financing of treatment for mental health and substance abuse problems have been inherently problematic. Insurance coverage for mental health and substance abuse care has been limited and frequently has not covered the prolonged treatment that consumers and families need to address complex problems.

• The separate publicly-financed health care system creates incentives for the private sector to limit benefits and thus to undermine the basic purpose of insurance; that is, to provide protection for large losses. Costly care is often shifted to the underfinanced public system, a process that is sometimes called “dumping.”

• Traditionally, the health care system inhibits access to care and tolerates poor quality of care, and thus contributes to poor outcomes.

• The problems of reduced access and increased cost shifting may be aggravated by the use of managed care approaches that focus exclusively on reducing costs.

• High-quality managed care, however, can provide tools to control costs in an integrated system. For example, case management for high-cost treatment can improve access to appropriate treatment while controlling costs.

• Existing measures and indicators are inadequate for use as evidence of dumping, skimming, and cost-shifting.

• Historically, the categorical and fragmented nature of public funding has contributed to fragmentation in service delivery.