Cultural Competence Standards in Managed Mental Health Care

Introduction

Increasing Diversity of the Consumer Population

America’s population is not only growing, it is changing dramatically. Present and projected changes in America’s ethnic composition challenge the capabilities of mental health systems. The U. S. population has always been multi-ethnic and its composition in flux (Bogue, 1985; Sutherland, 1966). However, popular awareness of different cultural groups has increased in the last few decades. Based on present population and growth rates, the U. S. Bureau of the Census (1996) predicts that the United States will undergo the population changes described below over the next half century:

Total Population Comprised by Different Groups (in millions)

 

Populations

1996 2050
Hispanic 27.8 (10.5%) 96.5 (24.5%)
African American 32.0 (12.1%) 53.6 (13.6%)
Asian and Pacific Islander 9.1 (3.4%) 32.4 (8.2%)
American Indian, Eskimo, Aleut 2.0 (0.7%) 3.5 (0.9%)
White 194.4 (73.3%) 207.9 (52.8%)
Total 265.3 (100%) 393.9 (100%)
Source:  U.S. Bureau of the Census, 1996.   Hispanic can be of any race: data for all other groups are non-Hispanic.

 

Shifts in ethnic diversity are not just about numbers, but also about the impact of cultural differences. In relation to mental health systems, new approaches are needed in service delivery to address cultural differences among consumers. It is important to note that culture is not simply determined by ethnicity and a particular set of beliefs, norms, and values. Culture also involves the historical circumstances leading to a group's economic, social, and political status in the social structure. Culture involves the circumstances and experiences associated with developing certain beliefs, norms, and values (Charon, 1995; APA, 1996). More specifically, this is especially true about the socioeconomic and political factors which have a significant impact on a group's or its members' psychological well-being (Mu�oz & Sanchez, 1997).

The essential point for mental health providers is that people develop different approaches in response to their life circumstances. Mental health providers are beginning to realize that cultural competence in diversity is an important component in providing effective mental health services. Therefore, it is important that mental health providers are aware of the underlying pattern and history of America's diversity (Mu�oz & Sanchez 1997).

 

People of African Descent

Demographic and Health Profile

Some scholars trace the history of African people in North America to 1619 (Bennett, 1966), while others propose that African people entered the Americas several centuries before that date (Van Sertima, 1976). During the period from 1619 to 1997, the proportion of people of African descent in North America has ranged between 10-19% (U.S. Department of Commerce, 1995) of the total population of the United States. In 1790, blacks constituted their largest proportion (19%) of the total U.S. population, and their smallest proportion (9.7%) was recorded in 1930 (U.S. Department of Commerce, 1995). The black population of the United States is growing at about 1.3% per year, one of the slowest growth rates of all populations in the country. In 1997, people of African descent numbered close to 33 million or 12.6% of the population in the United States. The majority (52.8%) of the black population in the United States resides in the South (U.S. Department of Commerce, 1995), although this figure is considerably lower than in previous decades. The smallest proportion (9.4%) of people of African descent reside in the West.

Between 1619 and 1860, the majority of the people of African descent came to the United States from the western coast of Africa as part of the slave trade that flourished during that era. Since 1860, growth in the population of people of African descent in the United States has come about primarily through births, which have continued to exceed the national family average. Although immigration of people of African descent into the United States has increased over past decades, black African immigrants remain the smallest number of all immigrants to the United States (U.S. Department of Commerce, 1995). Immigration of black people in the past decade from Egypt, Ethiopia, Ghana, Nigeria, Haiti, Panama, Jamaica, Trinidad, Barbados, and other Caribbean nations has significantly increased the nationalistic, cultural, religious, and language diversity within the black population in the United States (U.S. Department of Commerce, 1995). The terms African American and Black are used interchangeably here to refer to people of African descent.

Historical and current data about the health status of American populations confirms that there are very significant differences in prevalence and incidence of physical and mental health problems between groups based on culture, color, income, and country of origin. Also noted are major differences in help-seeking patterns (Neighbors, 1986). In two special reports (Center for Health Economics Research, 1993; Robert Wood Johnson, 1991), it was noted that people of color, particularly residents of inner cities, showed major disparities in their health status when compared to other populations. The disparities noted in the literature cover the range of disorders from high neonatal mortality rates per live birth, higher rates of heart and circulatory problems, disproportionate rates of AIDS and related deaths, greater prevalence of chronic conditions, higher rates of edentulism (toothlessness), and higher rates of admissions to psychiatric facilities (Center for Health Economics Research, 1993; Robert Wood Johnson, 1991). The high incidence of substance abuse, physical injuries, and deaths from violence greatly distinguish low income black neighborhoods and communities in terms of potential and actual costs of health care. According to some reports, substance abuse is the most significant health problem in the nation (Institute for Health Policy, 1993). These populations also show lower availability of health insurance and a significantly lower proportion of health professionals within easy access of their neighborhoods.

 

Historic Patterns of Mental Health Service Use

From the time that state governments decided to provide and finance residential care for the long-term mentally ill, major public policy paradoxes have been raised and debated about race and mental illness (Jarvis, 1844). The first of these paradoxes centers on the incidence and prevalence of severe mental illness in populations of African descent, while the second centers on the extent to which these populations require and consume public and/or proprietary mental health services (Snowden & Cheung, 1990).

A cursory review of the data on admissions to inpatient psychiatric facilities (Manderscheid & Sonnenschein, 1987; Scheffler & Miller, 1989; Snowden & Cheung, 1990) shows disproportionately high rates of admissions by African Americans to all types of inpatient facilities. This data (Manderscheid & Sonnenschein, 1987; Snowden & Cheung, 1990; Snowden & Holschuh, 1992) shows that between 1980 and 1992, the rate of admission for all persons to state hospitals in the United States was approximately 163.6 per 100,000. The rate for whites was 136, while the rate for Hispanics was 146 and the rate for Native Americans and Asians was 142 per 100,000 (Manderscheid & Sonnenschein, 1987). The admission rate to state hospitals for consumers of African descent for that same year was 364.2 per 100,000 population. Admissions to general hospitals with psychiatric units showed similar patterns by race and ethnicity. For the population as a whole the rate per 100,000 was 295.3 per 100,000, while the rate for the white population as a whole was 284.9. The rate during the same period for consumers of African descent admitted to general hospital psychiatric units was 386.6 per 100,000.

While the national mean admission rate to Veterans Administration Hospitals was 70.4 per 100,000, populations of African descent had a rate of 118.2 per 100,000. No other racial or ethnic population had an admission rate to the Veterans' Administration Hospitals that approximated the rate for populations of African descent. When age is examined, the relationship between admissions to psychiatric hospitals and race is more pronounced. For example, the rate of admissions to state psychiatric hospitals for consumers of African descent between the ages of 25-44 was 598 per 100,000, while the national mean was 163.6 (Manderscheid & Sonnenschein, 1987). The most excessive rate found was for consumers of African descent between the ages of 25-44 where 753 per 100,000 were admitted to state psychiatric hospitals (Manderscheid & Sonnenschein, 1987). Although admissions are not indicative of actual prevalence rates in the population, what is show clearly is a inveterate pattern of service utilization differentiated by race and class. Data drawn from the National Institute of Mental Health (Manderscheid & Sonnenschein, 1987) showed that blacks were more frequently diagnosed on admission with severe mental illness than other ethnic or racial populations. Admissions of blacks to state mental hospitals showed that 56% of these individuals received a primary diagnosis of schizophrenia, while only 38% of all individuals received a similar diagnosis. Garretson (1993), Flaskerud & Hu (1992), Jones & Gray (1986), and Lawson et al. (1994) conclude that the primary reason for the disproportionate rate of severe mental illness diagnoses are errors made by diagnosticians who are unfamiliar with mental illness as it is manifested in populations of color.

Decades of knowledge in the literature about how populations of African descent consume mental health services show that people of African descent:

*drop out of services at a significantly higher rate than white populations;
*use fewer treatment sessions for their mental health problems than white populations;
*enter mental health treatment services at a later stage in the course of their illness than do white populations;
*under-consume community mental health services of all kinds;
*over-consume inpatient psychiatric care in state hospitals at twice the rate of corresponding white populations;
*are more often misdiagnosed by mental health practitioners than white populations; and
*are more often diagnosed as having a severe mental illness than whites.

 

Managed Behavioral Health Care and Race: Implications

These data reflect a number of conclusions that may be helpful as the nation sets its course towards managed behavioral health care in the public and private sectors. First, it is clear that under the prior and present systems of care, consumers of African descent with serious mental illness: were and are not served well, diagnoses were found to have been in error, inpatient admission rates were disproportionately high; involuntary admissions were used with great frequency; and the most severe mental illness labels were ascribed at a rate that appears higher than its expected frequency in the population. Of significance as well are the findings of different patterns of help seeking and help utilization on the part of African American populations. Populations of African descent tend to delay seeking help for psychiatric problems (as well as major health problems) from formal health systems until conditions have become more serious or chronic and most other community and familial resources have been exhausted. Consumers of African descent also do not tend to remain engaged in outpatient services or utilize as many service units as other populations, although their diagnoses are more severe. Each of these conclusions portends important clinical and marketing issues for managed behavioral health care processes and values. As new managed care policies and services are being developed there is a greater need to focus more attention on the service issues and dilemmas related to race and severe mental illness. While a key aim of managed care policy and processes is designed to reduce unnecessary services and excessive costs, the role of race and service utilization remains poorly understood.

The paradoxes associated with race and mental illness are likely to impact disproportionately on low income communities of color with the implementation of managed care policies. For managed care to effectively serve consumers of African descent with severe mental illness, there will need to be a significant focus on issues of access, as well as accuracy of diagnosis and quality of treatment. Too often clinical issues are not examined from an ethnic or racial perspective because they do not fit the dominant cultural perspective. Even those professionals who have been educated in urban areas with large concentrations of minority populations may be conditioned to assess consumers using standards and guidelines that are not culturally specific or sensitive. In a behavioral health care environment that seeks to penetrate the market of consumers of African descent, there is a need to establish standards and guidelines for managed care systems, organizations, and providers.

 

Asian and Pacific Islander People

Who are the Asians and Pacific Islanders?

Asian and Pacific Islanders are often misunderstood to be a homogeneous ethnic group. Unfortunately, failure to make distinctions among the diverse ethnic, cultural, and language groups comprising Asian and Pacific Islanders, and tendencies to generalize their economic, social, and political circumstances, can lead to faulty conclusions about individuals' mental health needs.

Asian Americans are the fastest growing racial/ethnic group in the United States in terms of percentage increase. The American Asian/Pacific Islander population grew 108% from 3,726,440 in 1980 to 7,273,662 in 1990, thus constituting 2.9% of the entire U.S. population according to the 1990 U.S. Census (U.S. Bureau of the Census, 1991). Projections are that by the year 2020, the Asian American population will be approximately 20.2 million, or about 8% of the total U.S. population.

Asian Americans are also the most diverse group in terms of ethnic origin, cultural background, immigration history, and acculturation to U.S. culture. For example, Asian Americans comprise at least 31 ethnic groups. Their diverse immigration history spans over 200 years. The earliest immigrants came predominantly as indentured laborers, whereas more recently many Asian/Pacific Islanders have come to the U.S. as refugees escaping persecution in their home countries, and many more have immigrated in search of better education and economic opportunities.

Prior to World War II, the majority of Asian and Pacific Islander immigrants to the U.S. were from China and Japan. However, this has broadened to include many people from diverse Asian groups, such as Nepalese and Tibetans from Central Asia; and from Southeast Asia, Burmese, Cambodians, Laotians, and Vietnamese, who in turn have many different subgroups, among which the Hmong are perhaps best known. American Samoans, Guamanians, and Filipinos have also come in more significant numbers. Without negating these peoples' diversity, hereafter the terms Asian, Asian Americans, or Asian/Pacific Islander will be used when referring to them.

In 1990, 68% of Asian Americans were born outside the U.S. A myriad of issues surround this diverse immigration history, and contribute to a situation of economic polarity among Asian Americans. For example, disparate levels of language proficiency and education clearly contribute to this economic polarity. Unemployment among those of limited education and English language proficiency is double that of Asian Americans who are not disadvantaged in terms of education and language.

 

Asian Pacific Islander American Mental Health Issues

The accumulating evidence suggests that Asian Americans are experiencing significant mental health problems. Their diversity — the many ethnic groups, languages, cultures, value and belief systems, and immigration histories, as well as differences in present-day social, economic, and political circumstances — result in an equally diverse range of mental health concerns. The extent to which these issues become problems and how distress is expressed are thought to be affected by multiple factors that may include, but are not limited to: residence area; generational status in the U.S.; degree of acculturation, religious beliefs and value orientations, native language facility, English language proficiency; age, education, economic status, family composition, and degree of family dispersion; immigration as an unaccompanied minor; degree of identification with the country of origin; perception of choice in emigrating to the U.S.; social-political identification; and connection with formal and informal local networks.

Unfortunately, rates of psychopathology have been difficult to assess. It is believed that most existing estimates, which are based on utilization rates among clinical samples, seriously underestimate the actual need in the general Asian American population. Moreover, it is not known to what extent Western diagnostic criteria may overlook culturally-specific symptom expression and culture-bound syndromes. There is convergent evidence that Asian/Pacific Islanders underutilize mental health services, regardless of service type, based on reports comparing Asian American service use rates to their proportion in the general population. Several studies also report that Asian Americans exhibit more severe disturbances compared to non-Asians, suggesting that they are more likely to endure psychiatric distress for a long time, only coming to the attention of the mental health system at the point of acute breakdown and crisis. Further studies show that Asian Americans are more likely to drop out after initial contact or terminate prematurely from mainstream service settings. Studies have linked such underuse to the shame, stigma, and other cultural factors that influence symptom expression and conceptions of illness, as well as to limited knowledge about the availability of local mental health services, and a tendency to seek more culturally congruent care. The latter may include herbalist, acupuncturist, and other forms of indigenous healing. Increased utilization, longer treatment, consumer satisfaction, and positive therapeutic outcomes have been attained by culturally responsive, ethnic-specific services for Asian/Pacific Islanders which emphasize flexible hours, community-based facilities, bicultural and bilingual staff, and implementation of culturally congruent treatment plans.

 

Asian Pacific Islander Mental Health Service Delivery Issues

The data point to a great need for delivering more effective mental health services to Asian/Pacific Islander persons. Cultural competence is a fundamental component of providing effective mental health care to Asian/Pacific Islanders. Cultural competence is a respect for, and understanding of diverse ethnic and cultural groups, their histories, traditions, beliefs, and value systems. Cultural competence in mental health services is integrally important to all levels of care, including the structure and policies of service delivery systems, care planning for the individual consumer/family, and direct treatment intervention. As we transition into managed behavioral health care, cost-cutting and service restructuring threaten the quality of care to Asian/Pacific Islanders. Availability of care from culturally competent mental health specialists is a basic concern. In addition, coverage for family-oriented care plans, culturally appropriate interventions, linguistic interpreters, and alternative models of care are threatened. With these concerns in mind, the Asian/Pacific Islander national panel participated in developing the standards for providing culturally competent mental health care to the four groups.

 

Latino Populations

Demographic and Health Profile

The term "Latino(a)," as used in this publication, refers to all persons of Mexican, Puerto Rican, Cuban, or other Central and South American or Spanish origin. Latinos comprise significant populations in virtually all the United States, now numbering more than 27,800,000 people, or 10.5% of the national population, a 50% increase over 1980. It is projected to grow to 29 million by the year 2000 and 128 million by the year 2050. At that time, Latinos will clearly be the largest ethnic group in the United States. Latinos, or Hispanics, are widely recognized as being a major part of the fabric of the Southwestern United States, such as California, Texas, New Mexico, and Arizona. They can be found in significant numbers and percentages in such diverse states as Florida, Colorado, Nevada, New Jersey, Illinois, Utah, and Washington State. Latinos also have a significant presence in 25 metropolitan areas of the country.

The Latino population in the United States is not homogenous, but is composed of an extremely diverse group of nationalities of origin. These include 13.4 million of Mexican origin, 2.4 million of Puerto Rican heritage, Cuban, 1.1 million, and 2.9 million from Central and South American countries. Their cultural backgrounds are diverse, including Spanish, Aztec, Mayan, Incan, and Caribbean cultures, and Native American, White, and African American racial/ethnic origins. Their common language and link with Spanish culture serve as a means of considering them in unison, but their diverse religious, folk, family, and health beliefs and values as well as diverse linguistic idioms make them one of the most culturally rich groups in America. In addition to having Spanish as a common language, the people of Mexican, Puerto Rican Cuban, Central and South American origins also have a tendency to utilize mental health services less than the general population except under crisis situations.

Latinos have been adversely affected by under-education, under-employment, inadequate housing, and insufficient access to health care insurance. In addition, Latinos often perceive historic U.S. mental health models as unnecessary, unwelcoming, or not useful. Although it has never been firmly established, it should be assumed that the prevalence of mental illness is distributed relatively evenly among all peoples of the world. It may also be reasonably assumed, that if the tendency to be affected by mental illness is relatively the same, factors such as lower socioeconomic status and lesser access to resources will tend to exacerbate stressors and the accompanying need for mental health services.

In May, 1995, a national conference was held in Denver, Colorado. Well over 100 Latino mental health professionals from throughout the United States met and discussed the fact that Latinos, while affected by numerous socioeconomic stressors, remain likely to use mental health services primarily in crisis circumstances, drop out of services sooner, and have undesirable treatment outcomes. From that conference, a national panel was created to begin developing a set of national standards for delivering mental health services for Latino populations in a managed care setting.

When the panel began its work in January, 1996, several concepts were self-evident. Latinos have disproportionately less access to the full range of mental health services normally expected within any given state. They do not have comparable rates of use of ongoing outpatient services, have lower rates of voluntary hospitalization, and use crisis and other higher-cost services at higher rates than other populations.

Mental health staff who have trained in general practice often do not consider cultural competence as necessary or even valid. Thus, there is a tendency not to incorporate cultural competence principles in service development and planning models at the local and state level, nor to use those principles in direct service delivery.

These factors are particularly important when comparing briefly a Fee for Service to a Managed Care service model. In a Fee for Service environment, any service provided to a client results in a revenue to the organization which provided the unit of service. In a Managed Care or capitated rate environment, delivery of a service to an individual becomes a cost; and the fewer the services delivered in a set rate environment, the higher the profits. If Latinos have underutilized mental health services in a Fee for Service environment where there are incentives to the provider to deliver the service, it follows that Latinos are more at risk in a Managed Care environment. In the Managed Care context, service delivery becomes a cost to an organization which is paid a flat rate per person served, irrespective of what the total price of service might be.

One further consideration is important. In a private insurance setting, the Fee for Service versus Managed Care example is particularly true, in that there is the ability to limit costs by limiting services. When the total number of sessions or hospitalization days allowed by an insurance company is exhausted, the remaining costs become the responsibility or burden of the insured. In a public setting, governmental sponsors expect that provider organizations will deliver certain outcomes within a fixed or capitated rate and be financially at risk for costs above that.

Thus it becomes critical that costs be managed by delivering services effectively rather than by limiting benefits. In this environment, it becomes critical to understand access and utilization patterns, outcomes, outlyers, and cost by groups and by types of service. In this environment it becomes very important to understand service groups' and subgroups' needs in order to meet them effectively and attain desirable outcomes within a fixed cost.

The Latino national panel based much of its work upon the above concepts and several other assumptions:

*cultural competence results from a specialized practice development rather than from having been born in , or having spent significant amounts of time in a culture, or by a general practitioner using an interpreter, regardless of the interpreter's linguistic expertise;
*qualifications of Latino mental health specialists should include performance-based competency verification; � developing specialized instruments, protocols, and outcome measures shall continue;
*additional methods for testing and confirming the viability of specialized practice shall also continue; and
*developing culturally competent standards augments the general body of knowledge, not at the expense of service to others.

 

American Indian, Native Alaskan, and Native Hawaiian Populations

Demographic and Health Profile

The opportunity to highlight literature and articulate current thinking about what constitutes culturally competent mental health diagnosis and treatment of Native Americans is welcome. Although very little has been written that directly addresses managed care for Native American populations, there is a foundation of writing and thinking that is relevant to this issue; however, this body of knowledge is emerging and far from complete. In the United States, the terms Native American, Indian, and American Indian are commonly used and have been considered interchangeable when referring to aboriginal people of the continental United States, i.e., American Indians, Eskimos, and Aleuts. In this document, Native American also includes the natives of Hawaii.

A rich diversity exists among the hundreds of tribes and villages, and within urban Native American communities. Among the better known tribes are the Apache, Cherokee, Navajo, Iroquois, and Sioux (Lakota), but there are numerous lesser-known groups throughout the country. To name a few, there are the Cahuilla, Gay Head Wampanoag, Mississippi Choctaw, Red Lake Chippewa, Shivwits, and Tlingit. Census data for 1990 reported approximately 1.9 million American Indian, Eskimo, and Aleut people in the United States (U.S. Bureau of the Census, 1991). About half live on federal Indian reservations in 33 states, mostly located in the western states. The other half lives in urban areas, although some reside in small off-reservation communities. The Indian population is young; approximately half are 18 years of age or younger (Nelson, McCoy, Stetter, & Vanderwagen, 1992). Of the 211,014 Native Hawaiians living in the U.S. in 1990, the majority (138,742 or 66%) resided in Hawaii (U.S. Bureau of the Census, 1991). This population faces severely poor health conditions (Mokuau, 1990); Native Hawaiians have the shortest life expectancy of any ethnic group in Hawaii (State of Hawaii, 1987).

Many American Indian and Alaska Native groups have sovereign nation status with the federal government of the United States. For most Indian tribes, sovereignty was specifically retained when they signed treaties with the United States government. They are recognized as distinct political entities operating within the American government system, which is the "nation within a nation" concept. Today, Hawaiian Natives are also seeking to restore their sovereign nation status, which was lost at the time of the overthrow of the Hawaiian monarchy.

The importance of mental health services to Native people can be understood in historical, geographical, educational, and tribal contexts. It is import to understand the impact of colonization on Native people and corresponding issues of mental health (Duran & Duran, 1995). Although some early contacts between Native peoples and Europeans were positive, most were not. At contact there were several million Native Americans. From the point of initial contact with Europeans, holocaust conditions led to the annihilation of some, and near destruction for other tribes across the Americas and the Hawaiian Islands. Diseases foreign to Native people wiped out over half of the American Indian population, and the impact of these diseases is still being felt in Native country. Disease killed many leaders and elders, thus cutting off tribal leadership, as well as the sources for knowledge and tradition. Furthermore, the power of the medicine people was undermined, because there were no cures for alien diseases about which they had no knowledge. Memories remain among Native Americans about what Whites did through deliberately providing them with infected blankets as "gifts" — an early form of germ warfare (Vogel, 1972).

Forced relocation was another factor which caused many deaths as well as numerous other problems, many of which were mental health related. Dealing with the reality of being conquered, the shame, the forced dependency upon the U.S. government, and the stripping of traditional roles from men, women, and children has impacted tribes for centuries. The pain of the "Trail of Tears," or long walks made by tribes, remains in the hearts and minds of American Indians today. Other impacts of forced relocation include: dealing with broken treaties, being restricted to reservations (historically, an Indian had to have a permit in order to leave the reservation), poverty conditions, and the consequences of not relocating, which often meant destruction and death (O'Sullivan & Handal, 1988; Vogel, 1972). Alcohol was another devastation (Berkhofer, 1978) and is considered to be the number one problem in Native American country today.

Forced education through boarding schools caused considerable damage to the structure and function of tribal societies as well as to the mental health of Natives. Historically, Native American children were taken from their tribal homes to attend boarding schools sometimes hundreds or thousands of miles away. They were forbidden to speak their tribal language, given new names, usually a uniform, their hair was shorn, and they were taught the ways of White society. The early charters for Native American education were the same: to remove the child from the influence of his or her "savage" parents. Today, approximately 25% of Native children attend boarding schools. The horrible effects of boarding schools on tribes extend to the undermining of tribal ways of parenting, traditional child-rearing, use of language (many a story about a child finally returning home and being unable to speak to his or her parents any longer), the negative messages about Natives, and the forced assimilation of White ways have had devastating consequences. Today, there are counseling groups specifically designed to address the effects of boarding school education experiences.

In terms of health care, the U.S. government has had this responsibility through the obligations of many treaties. Typically, these obligations were carried out through the Public Health Service via the Indian Health Service (IHS) and Bureau of Native Affairs (BIA). The Public Health Service in 1955 assumed primary responsibility for providing health care to Native Americans, and currently IHS services approximately 60% of the Indian population (Johnson, 1995). IHS services include clinical care as well as environmental health, facility maintenance, and critical public health functions. The hope was, that once this was fully developed and comparable to the nation's health care systems, Congress could then relinquish its responsibilities to American Indians. This goal was part of the termination policy formulated by Congress during the Truman and Eisenhower administrations. Under Nixon's self-determination policy, tribes were encouraged to take over governing their health care programs (Flack, 1995). Under Public Law 93-638, 300 tribes across the nation now compact or contract with the federal government to provide part or all of the health care for their tribal members. Furthermore, there exists 41 urban Indian health clinics, which although enormously underfunded, attempt to serve the most disadvantaged Indians and those from distant tribes who may not be eligible for IHS contract services.

Presently, there are numerous agencies/departments involved to varying degrees in providing mental health services to Native Americans. At the broad systems level, there is a lack of clarity regarding the roles of the IHS, the BIA, states, counties, cities, and tribes in mental health care. There are relatively few working agreements among these service delivery systems (WICHE, 1993).

Native Americans appear to be at higher risk for mental disorders than most ethnic groups in the United States (Nelson, McCoy, Stetter & Vanderwagen, 1992). Of great concern is the high prevalence of depression, anxiety, substance abuse, violence, and suicide. Other common mental health problems of Native American individuals are psychosomatic symptoms and emotional problems resulting from disturbed interpersonal and family relationships (Neligh, 1990).

The Native American Panel has many concerns about managed care as a model of health care delivery for Native Americans. Of particular concern is the use of a prepaid or capitated approach to service payment. Issues affecting Native American people are complex and linked to historical events and current experiences which are perpetuated by current events, that on the surface, do not seem related. However, because of the historic trauma experienced by many Native Americans, subtle messages that communicate a lack of belonging to contemporary American society and the continuing assault on Indian sovereignty serve to perpetuate mental health problems. Managed care organizations which do not address these complex issues in a careful and thoughtful manner with Native American consumers, sovereign tribal nations, native organizations, and relevant federal agencies will only add to the oppression experienced by Native Americans for decades.

Having stated these concerns, the Native American Panel offers the following guidelines toward the goal of developing culturally competent managed care organizations which would serve Native Americans in ever-increasingly effective and respectful ways. In reviewing the system and clinical guidelines, we agreed that guidelines for Provider Competencies would be the same regardless of the setting (urban, suburban, rural, or reservation). All other guidelines were reviewed, with rural-reservation managed care settings kept separately in mind from urban-suburban settings. It is highly likely that the urban-suburban managed care settings would be non-Native American and most likely, non-minority specific. In considering the rural/reservation situation, we found it useful to use the Navajo Nation as a reference point. The Navajo Nation has sovereign nation status over its membership residing on or near the reservation, a very large geographic area located in three states (Arizona, New Mexico, and Utah). This illustrates the complexity in developing culturally competent health care for one tribal nation.

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Managed Care in the Delivery of Mental Health Services

The transition into managed care in the delivery of health care services has had an impact on both private and public behavioral health systems. As this transition is taking place, a number of potential risks have surfaced. Professionals and organizations representing individuals from the four groups have concerns about how these major shifts will affect all ethnically diverse populations. Some of these concerns include:

*Cost-cutting that potentially threatens the quality of care;
*Restructuring of services away from local, community-based approaches;
*Relocation of services threatening accessibility;
*Services provided to consumers from the four groups by mental health professionals not familiar with the language, cultural values, and multiple needs of the different groups;
*Consumer lack of knowledge about how the health care system works; and
*Language barriers interfering with communication and access to resources.

The authors of this document acknowledge that this shift to a new health care delivery system offers a number of potential opportunities for behavioral service delivery as well as for the racial/ethnic communities. Some of these potential opportunities include:

*Increased accountability for services provided;
*Flexibility of care options to consumers;
*Competition for service providers to provide maximum value for the Medicaid consumer dollar;
*Greater cost-efficiency through:

  • More accurate assessment and effective treatment;
  • Use of culturally competent, less restrictive community-based treatment approaches;
  • A shift from more restrictive and expensive services to earlier use of services, leading to secondary prevention;
  • Use of traditional healers in conjunction with traditional western mental health approaches;
  • Partnership with community organizations for health promotion.

*Greater acceptability through:

  • Culturally friendly location and ambiance;
  • Community input in design and governance.

To frame the opportunities outlined above, the authors have developed the Guiding Principles and Standards that follow.