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  • A recent trend is to combine Medicaid funds with other state and local public funds in the financing of public systems.

  • The fundamental problems in mental health and substance abuse care cannot be fully addressed without changing the structure and financing of the system and attending to the problem of the separate public and private sectors of care.


1.1 The reform of systems of care financed by states and counties must: (1) recognize current aspects of private health care in those states and counties and (2) consider the design and development of mechanisms to inhibit cost-shifting.

1.2 Payment arrangements that reduce incentives to underserve individuals with behavioral health conditions should be encouraged.

1.3 The reform of state and local systems through the use of managed care should incorporate a recognition of and responsiveness to the unique needs of consumers served by public systems.

1.4 Accreditation organizations, when appropriate, and purchasers should develop criteria and guidelines that: (1) recognize and measure dumping, skimming, and cost-shifting; and (2) specify rewards for organizations, groups, and individuals that provide appropriate care and penalties for those that do not.

1.5 Purchasers should ensure continuity of care for consumers when managed care contracts are awarded to different provider organizations.


  • The wide array of consumer and quality protections includes accreditation, performance measurement, clinical practice guidelines, state licensure, and contract requirements. Some of these functions overlap.

  • Accreditation of managed care plans by independent national bodies is an important and powerful tool of consumer protection and quality improvement in health care and behavioral health care.

  • Accreditation of service delivery organizations, such as hospitals, is well developed, but accreditation of managed care plans is in its infancy.

  • In the field of managed behavioral health care, accreditation alone is not sufficient to guarantee high-quality care.

  • Currently, multiple competing organizations perform measurement, reporting, and accreditation functions in the health and behavioral health care sectors. In the behavioral health care area, the Rehabilitation Accreditation Commission (CARF), Council on Accreditation of Services for Families and Children (COA), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), National Committee for Quality Assurance (NCQA), and Utilization

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