Consumer-Staffed Monitoring Teams In Managed-Care Assessment
by E. Clarke Ross, D.P.A., NAMI deputy executive director for public policy
The need to document consumer satisfaction is a core premise of managed care. But who does the documenting is fundamental to the meaningfulness of measures of satisfaction. And the concept itself-satisfaction-is questionable; many advocates have concluded that dissatisfaction and the health plan's ability to immediately respond to dissatisfaction are much more significant than satisfaction. All healthcare systems-not just managed care-must incorporate valid mechanisms to document and affirmatively respond to dissatisfaction.
The use of independent, third-party, consumer- and family-staffed organizations is basic to NAMI's evolving agenda to ensure accountability by all participants in the healthcare arena-payers, purchasers, health plans, management agents, delivery systems, and providers. Fortunately, several public mental health systems are launching the use of consumer- and family-staffed consumer-interview teams to assess-and to obtain when lacking-health plan responsiveness to dissatisfaction. Massachusetts, Michigan, Ohio, and Pennsylvania are rolling out such consumer-based initiatives as part of their managed care accountability approaches. Alabama, Georgia, Washington, and Wisconsin are also using such teams in limited areas of their public mental health systems.
First funded by the county, one of the very first in the nation, and probably the most advanced in terms of operational experience is Philadelphia's Consumer Satisfaction Team, Inc., whose executive director is the immediate past-president of NAMI-Pennsylvania, Loretta Ferry. In 1990 the city of Philadelphia, which has been developing a consolidated mental health service system and today operates a citywide single managed behavioral healthcare system, developed a consumer satisfaction team (CST). The mission of the CST, as articulated by Loretta, is to try to understand and communicate back to the funder of services what consumers like or do not like about those services. Recognizing that it often takes a long time to build trust with a person with serious and persistent mental illness, the CST in Philadelphia conducts multiple interviews with the same consumers over the course of a year.
CSTs provide written documentation of each consumer visit and hold regular meetings with the payer. With Philadelphia's development of a managed care program in 1996, the CST expanded its responsibility to include consumer outreach and education. Also in 1996, the scope of the CST was broadened to include people with addictive disorders as well as those with serious mental illness.
In early 1996 the Center for Mental Health Services' (CMHS) Mental Health Statistics Improvement Project (MHSIP) introduced a prototype consumer-oriented report card for consumers to use to evaluate managed care. NAMI board of directors member J. Rock Johnson, J.D., was actively involved in this effort, and Elizabeth Edgar of the NAMI staff is NAMI's link with the MHSIP. There has been much debate about the feasibility of collecting uniform data for this report card. A core premise underlying MHSIP is that information focused on the consumer's individual life situation should be the basis of any report card effort. NAMI goes further and argues that those directly affected by mental illness should collect information about consumers.
Most managed care organizations (MCOs) use their own internal marketing or, hopefully, quality-assurance teams to determine consumer satisfaction. Whether marketing or quality-improvement staff, they are internal employees of the organization. Marketing staff tend to focus on overall satisfaction, and they assume that when overall rates of satisfaction are high, everything is basically OK. Quality-improvement staff tend to focus on areas of operation requiring improvement. This is helpful, but still skewed by the situation of internal staffing. Some MCOs use outside agencies, most frequently university departments or professional surveying organizations, which avoids the internal staffing bias; however, they may not fully understand the situations of consumers and family members directly affected by mental illness.
NAMI board of directors member Fred Frese, Ph.D.; NAMI Ohio President Velma Beale, M.A.; and NAMI Ohio former Executive Director Krista Magaw have been directly involved in the development of an Ohio Department of Mental Health project that has lead to the publication of Vital Signs: A Statewide Approach to Measuring Consumer Outcomes in Ohio's Publicly Supported Community Mental Health System. (Dr. Frese has also been involved in a three-site Veterans Administration consumer-team approach.) Ohio holds that "outcomes should be measured primarily from the perspective of consumers" and that this process should be an innovative and incremental addition to Ohio's benchmarking, database, and continuous-quality-improvement strategies.
A recommended advocacy strategy
Numerous research studies have verified the validity and usefulness of patient-satisfaction measures in assessing the efficacy of clinical care. So, what should every NAMI organization advocate for with every health plan, whether public, private, managed care, or fee-for-service?
- The creation of an independent, third-party monitoring team of family members and consumers to assess the dissatisfaction enrollees have with their health plan. (It will always be a challenge to determine the difference between substantial and frivolous dissatisfaction.)
- The commitment of the health plan to routinely meet with the consumer/family interview teams and to immediately work to correct identified problems. Immediate response is crucial.
- The collection and aggregation of health-plan and provider-performance dissatisfaction data, the documentation of health-plan and provider responses to dissatisfaction, and the public release of resulting information to help individuals make informed choices about enrollment in the health plan and about providers.