Defense Health Care:

CHAMPUS Mental Health Demonstration Project in Virginia

HRD-93-53: Published: Dec 30, 1992. Publicly Released: Jan 12, 1993.

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Pursuant to a congressional request, GAO reviewed the Department of Defense's (DOD) mental health demonstration project for Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) beneficiaries, focusing on: (1) the extent of program cost-savings; and (2) whether DOD oversight was adequate to ensure CHAMPUS beneficiaries' access to quality care.

GAO found that: (1) the project's total costs were less than projected totals and averaged about $32 million annually; (2) DOD realized savings of $148 million in comparison with nationwide CHAMPUS mental health care costs; (3) reasons for the project's savings included shifts in utilization patterns from inpatient services to less expensive partial hospitalization and outpatient services, and reductions in provider reimbursement rates; (4) DOD oversight and contractor controls were insufficient to ensure CHAMPUS beneficiaries access to quality treatment; (5) DOD has not provided for effective independent project evaluation or quality-of-care monitoring; and (6) the mental health care contractor's system for assessing and authorizing care may restrict access to care and limit identification of quality treatment problems.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: The National Quality Monitoring Contractor began operations on October 1, 1993, and will review utilization and quality-of-care decisions made by all mental health contractors. DOD will receive quarterly reports, determine corrective action, and sanction providers as appropriate.

    Recommendation: In designing future mental health care projects, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to ensure that an effective independent quality-of-care monitor is established, and a system to follow-up on findings and implement corrective action is implemented.

    Agency Affected: Department of Defense

  2. Status: Closed - Implemented

    Comments: The study on outpatient care was sent to DOD on August 3, 1993, for comment. The study recommends that several additional studies be performed. The study identified several monitoring systems and procedures that would help determine the appropriateness of outpatient care. DOD developed guidelines for mental health assessments and treatment plans and follow-up procedures for outpatient records that lack the appropriate documentation.

    Recommendation: In designing future mental health care projects, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to implement management controls to review and monitor the appropriateness of outpatient mental health care decisions.

    Agency Affected: Department of Defense

  3. Status: Closed - Implemented

    Comments: DOD adjusted the contractor procedures, which were unique to the demonstration project, so that beneficiaries were allowed greater access to hospitals, particularly in emergencies. This change will be incorporated into future contracts for mental health care. However, DOD does not agree that the definition of an emergency requires changing.

    Recommendation: In designing future mental health care projects, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to redefine "emergency admissions" so that CHAMPUS beneficiaries in crisis can be stabilized and obtain necessary assessments in an emergency department without leaving a hospital to have treatment assessments done by a contractor.

    Agency Affected: Department of Defense

  4. Status: Closed - Implemented

    Comments: DOD awarded a contract to monitor quality of care nationally (see recommendation 1). The contractor will help develop procedures to document mental health care processes and quality assurance results. Also, DOD's proposed contracts include requirements for comprehensive internal quality-monitoring and improvement programs.

    Recommendation: In designing future mental health care projects, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to improve and maintain documentation of all internal processes designed to ensure that appropriate decisions are being made and develop internal systems that document the use of internal quality assurance results to help identify potential failures or errors of the managed mental health care system.

    Agency Affected: Department of Defense

 

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