PEERING INTO THE BLACK-BOX - MEASURING OUTCOMES OF MANAGED CARE

Research on the impact of managed care on access, quality, outcomes, a nd costs of mental health and substance abuse services has been limite d because of the lack of generalizability of studies, the ''black box' ' focus of much of the research, the dynamic changes in mental health and substance abuse managed care, and the proprietary nature of the he alth care industry. This article provides a framework for understandin g the organizational, financial, and procedural features of health pla ns and the effect of these features on the characteristics and flow of patients through health plans and the selection and utilization of tr eatments. The diverse research priorities of key stakeholders, ie, pub lic and private purchasers, managed care organizations, providers, and patients and their families, are described along with a broader socie tal agenda for delineating the outcomes of health care plans. Critical research and methodologic issues in studying the effects of managed c are are outlined, including issues related to identifying and selectin g appropriate outcome measures and developing appropriate methods for risk adjustment to adequately control for patient selection bias. This article asserts that government, purchasers, health care plans, provi ders, consumers, and researchers must collaboratively develop resource s and research approaches to fully evaluate the effects of managed car e. To realize this objective, auspices with reasonable objectivity are needed along with access to necessary data within the black box of he alth care systems, a cadre of trained investigators, and sufficient re search funding, including the development of an all payers fund to sup port clinical and health services research.