Managed Care: Strengthening the Consumer Voice in Managed Care: II. Moving NCQA Standards From Rights to Empowerment

NCQA standards reflect the three main approaches American psychiatry has taken to the role of the consumer since World War II—rights, satisfaction, and empowerment (6).

As measured by the three components of accountability for reasonableness—transparency, deliberation, and appeals and revision—NCQA's behavioral health standards provide strong support for transparency and appeals and revision and represent a good start for deliberation. The main changes for strengthening the consumer's voice involve specifying who should participate in deliberation about policy and how that deliberation should be conducted.

With regard to who participates in policy deliberation, the 2001 standards already require consumer participation in the domains of quality improvement and prevention. The next set of standards should extend that requirement to the utilization management domain, which is where the rubber meets the road in managing resource use. Utilization management standard 2.2 currently requires the managed behavioral health organization to involve "appropriate, actively practicing practitioners in its development or adoption of [utilization management] criteria." In the next set of standards, a phrase such as "and enrollees" should be added after "practitioners."

In the quality improvement domain, a one-word change could substantially strengthen support for accountability for reasonableness. We have observed programs in which consumers receive reports of completed quality improvement projects under circumstances that allow for passive listening but no meaningful participation. This perfunctory form of show-and-tell would meet the current requirement "that practitioners and enrollees help to plan, design, implement, or review the quality improvement program" (quality improvement standard 2.3). Changing "or" to "and" would be consistent with best practices for managed behavioral health organizations and would raise the expectation bar in a meaningful way.

With regard to how policy deliberation should occur, the 2001 standards convey a clear understanding that managed behavioral health programs are responsible for meeting the needs of both the individual and the population in the context of inevitably limited resources (prevention standard 1). The essence of managed care is setting priorities and considering cost-effectiveness (utilization management standard 3) within the resource pool. Thus decisions about policies should be based on considerations that are relevant to meeting individual and population needs within resource constraints. NCQA standards can strengthen and enforce this expectation.

The strongest expectations about the rationale for policies are in the standard for denial notices, which requires that a managed behavioral health organization "clearly documents and communicates the reason for each denial" (utilization management standard 6). Commendably, the NCQA manual gives five examples of acceptable reasons and three examples of unacceptable ones.

One example of an acceptable reason listed in the manual is, "The enrollee no longer requires care in a hospital because he/she is not a danger to self or others and can be appropriately managed in an intensive outpatient program" (utilization management standard 6.2). Although this reason would be vastly better than "the treatment is determined to be not medically necessary," which is listed as an example of an unacceptable reason, it is not good enough. Suppose that hospital care is not clinically contraindicated, and the patient, the family, and the practitioner all prefer hospitalization to intensive outpatient treatment. Perhaps a 22-year-old patient's continued paranoid utterings are disturbing the younger children at home, or the patient, the family, and the practitioner believe the patient's medication could be fine-tuned better in the hospital. In these circumstances they would not and should not be satisfied by NCQA's reason.

What would satisfy these individuals, other than coverage of the continued hospital care they desire? In a prepaid group practice—or in a Canadian province (9)—a reason such as the following might lead them to see the denial as fair, although disappointing: "In order to offer the fullest possible range of services to the insured population within our budget, our clinical policy calls for the use of alternatives to hospitalization whenever possible." In a self-insured or commercial account, a reason such as the following might have the same result: "In order to offer behavioral health coverage to our employees at an affordable price, our clinical policy calls for the use of alternatives to hospitalization whenever possible."

Of course, the persuasiveness of these reasons would depend on their being true. By requiring that explanations of denials include reasons that would be considered fair by the recipient, NCQA could advance the honesty of the climate in which care is managed and put pressure on managed behavioral health organizations to be more accountable for the reasonableness of their policies and practices.

NCQA intends to maintain its current set of standards until June 30, 2003, which gives consumer advocates ample time to explore ways in which the next version could further strengthen the consumer's voice in managed behavioral health care. The suggestions we have made would promote greater transparency about the provision of health care in the context of finite resources and more robust consumer participation in the policy-making process.

Although our suggestions involve small changes in the wording of standards, if taken seriously they would produce significant changes in the way managed behavioral health organizations conduct themselves. Applying accountability for reasonableness would require a substantial societal learning curve. Promoting such learning is consistent with NCQA's mission of supporting progressive quality improvement and public education.

The authors thank Burt Johnson, M.D., and Tom McLaughlan, Sc.D., for their helpful reading of the manuscript and the Greenwall Foundation and Open Society Institute Program on Medicine as a Profession for its support.

Dr. Sabin, who is editor of this column, is clinical professor of psychiatry at Harvard Medical School and director of the ethics program at Harvard Pilgrim Health Care, 133 Brookline Avenue, Sixth Floor, Boston, Massachusetts 02215 (e-mail, [email protected]). Dr. O'Brien is director of quality management at ValueOptions in Dedham, Massachusetts. Dr. Daniels is Goldthwaite professor in the department of philosophy of Tufts University in Medford, Massachusetts, and professor of medical ethics in the department of social medicine at Tufts Medical School in Boston.