This particular report focuses on level-of-care criteria used in the private sector-the policy documents whereby managed care vendors make decisions to approve or deny authorization of and payment for services. We selected this as our first area for study because it has such tremendous impact on access to care, as well as the appropriateness of the treatment consumers receive. When level-of-care criteria are incomplete, poorly defined, or too stringent, they create unnecessary obstacles for consumers who need mental health services. And these obstacles result in their deterioration, prolonged and unnecessary suffering, and even death.

Despite the existence of many national accrediting and quality monitoring bodies, there is very little information available that compares the quality of operational policies under managed care, including treatment authorization policies. The task of collecting such information is difficult because each vendor manages a broad collection of customized benefit plans and operational procedures for its clients. And unlike public sector contracts where, by law, contracts must be publicly available, in the private sector, many vendors can and do label a significant portion of their operational procedures proprietary trade secrets.

As a result, there is little means to compare "apples to apples" among managed care vendors. More importantly, there is very little opportunity to hold up the better practices that have been accomplished as models that other vendors can replicate. In the face of these obstacles, NMHA proposes to fill some of this gap through qualitative comparison of key policies that are standard across a large percentage of any given vendor's book of business, beginning with level-of-care criteria.

This report includes descriptions of more than 45 best practices and more than 45 worst practices identified in the criteria sets, as well as specific text extracted to illustrate the findings (all direct quotations from criteria sets are provided in italics). In addition, in a small number of areas where best practices could not be identified, we have proposed some protocols to improve these policies. Of note, many of the worst practices were "errors of omission" rather than "commission" (i.e. substantive areas that vendors failed to address, rather than addressed poorly). Our hope is that this information could be used to:

• Help these vendors improve their systems, drawing on the best practices that have been successfully implemented in the marketplace to date. NMHA will meet with individual companies to congratulate them for their own best practices and to propose operational policy improvements, where appropriate.

• Help benefits consultants, employers, insurers, managed care organizations, and other payors make more informed decisions when selecting among prospective bidders to manage mental healthcare services. NMHA plans to share this information widely with the private sector purchaser community.

• Help clinicians make more informed decisions when selecting among vendor subcontracts.

It is important to note that the reports produced as part of this project are based only on the operational policies provided on paper by the vendors included in the study. We believe this is an essential first step that will need to be followed by a second generation project addressing the implementation and ongoing application of such policies, as well as their impact on mental health consumers and their families.

We hope that all readers of this and future reports will use this information to ensure that as many of the best practices identified become common practices. If we can provide support in these efforts, please contact NMHA's Advocacy Resource Center for additional assistance (1-800-969-NMHA (6642), Option 6).

NMHA looks forward to working with managed care organizations and purchasers to replicate the best practices identified in this report. We thank our readers for their ongoing commitment to improving the quality of private sector managed mental health services.

Key findings

"Report card" on information sharing

Methodology

Development process

Comprehensiveness

Corporate philosophy

Access issues

Compliance

Child and family issues

Substance abuse and co-occurring disorders

Cultural competence

Provider autonomy

Coordination/ consultation among providers

Denial notification and appeal processes

More observations, recommendations and areas for further study