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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH
A principle in biomedical ethics that refers to having respect for every individual's independence and freedom of choice. This is usually expressed as the need to obtain informed consent from an individual or his or her representatives before undertaking treatment.
Managed care term that applies to the assessment and treatment of problems related to mental health and substance abuse. Substance abuse includes abuse of alcohol and other drugs.
For a particular indicator or performance goal, the industry measure of best performance. The benchmarking process identifies the best performance in the industry (health care or non-health care) for a particular process or outcome, determines how that performance is achieved, and applies the lessons learned to improve performance (NCQA, 1995, p. 45).
A fixed rate of payment to cover a specified set of health services. The rate is usually provided on a per-member per-month basis (IOM, 1989, p. 288).
A decision to purchase separately a service that is typically a part of an indemnity or health maintenance organization plan. For example, a health maintenance organization may “carve out” the behavioral health benefit and select a specialized vendor to supply these services on a standalone basis (United HealthCare Corporation, 1994, p. 16).
Any individual who does or could receive health care or services. Includes other more specialized terms, such as beneficiary, client, customer, eligible member, recipient, or patient.
Individuals who have more than one disorder, for example, a depressed person who also is an alcoholic. Usually, the term is used to refer to a combination of mental health and substance abuse problems, but it can also refer to individuals who have a behavioral health diagnosis as well as a medical diagnosis or disability.
The part of health expenses that are paid by the person who receives services, including deductibles and copayments.
The process of assessing and validating the qualifications of a licensed independent practitioner to provide member services in a health care network or its components. The determination is based on an evaluation of the individual's current license, education, training, experience, current competence, and ability to perform privileges requested. The