Analysis of the structure of the behavioral health care service system requires a review of the public and private service systems for both substance abuse and mental illness. The behavioral health care delivery system involves a complex combination of public and private financing as well as public and private practitioners of care. Public-sector services are financed either with state and federal appropriations or through Medicaid and Medicare coverage and are delivered in a wide variety of treatment settings. Private systems of care have different structures but coexist and often overlap with public sector services. Workplace service systems (e.g., employee assistance programs) and managed behavioral health care strategies have had a stronger influence in the private sector, but they are beginning to develop linkages with public agencies.
Federally supported service systems developed by the U.S. Department of Defense and the U.S. Department of Veterans Affairs share characteristics of both the private- and public-sector systems of care but represent separate and distinct service systems. In addition, service systems also exist for distinct populations: children, seniors, and Native Americans. The existence of a large number of independent service delivery systems serving different populations through different funding streams complicates the assessment of quality and can inhibit the development and implementation of comprehensive standards to improve the quality of care.
Managed behavioral health care organizations define access and accessibility using utilization (e.g., penetration rates and the use of specific services) and telecommunication (e.g., on-hold time and call abandonment rates) measures. Purchasers, however, may prefer to view access more broadly and include reductions in barriers to care and improvements in benefits (e.g., reductions in copayments, increases in hours of service, reductions in travel time, and expanded eligibility for specific services or populations).
The nature of managed care and the nature of mental illness and substance abuse combine to make access a most critical issue. Well-developed public and private health care and behavioral health care plans will promote access to mental health and substance abuse services. Enrollees that access care promptly and early in their illness episode may require less intensive care, and with appropriate continuing support they may be less likely to experience relapses.
Measures of access, however, should go beyond telephone answering time and begin to reflect the real and perceived barriers to care including cultural differences, geographic distance, inconvenient locations and times, and care that is less intensive than needed. Moreover, the purchasers of health care plans and the plan administrators must begin to assess the adequacy of their current access. In