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benevolent employer was firmly reinforced by years of unions' struggles with management and by a healthy economy under which employers could afford to offer generous health benefits.

For years, the health insurance contract offered ever-increasing benefits, freedom of choice, and first-dollar coverage (few copayments or deductibles). Employers trusted their employees and providers. Although consumers and providers struggled for many years to develop more adequate mental health and substance abuse benefits, most people were happy with the health care system. Furthermore, the U.S. Congress initiated the Community Mental Health Centers Act, Medicare, Medicaid, Hill-Burton, and other programs (see Chapter 3), which contributed greatly to the growth of the health care industry. With these investments, the public and private sectors created health care access and resources that were unparalleled in world history.

Fueled by scientific prowess and expanding financial commitments, the health care system appeared to have no limits in its potential capacities to provide health care. However, unlimited growth could not continue. With the rising costs of health care services threatening the financial stability of their budgets, private and public payers increasingly turned to methods that make health care accountable and affordable and that prevent cutbacks in previously reimbursed health benefits. The widespread initiation of utilization management, health maintenance organizations (HMOs), and other managed care methods during the past quarter century has emphasized cost accountability (IOM, 1989a).

These programs have cumulatively evolved into an industry and have become a strong force in the health care system. Consumers and providers who believe that autonomous health resource decisions on the basis of tradition and the health care contract are consequently in conflict with such policies. The tensions over cost controls have increasingly focused concerns about cost-containment efforts on quality issues such as the following:

  • qualifications of and consumers' geographic access to a comprehensive range of providers;

  • prevention of avoidable illness and provision of timely and focused treatment interventions;

  • availability of services, on the basis of urgency of need;

  • courtesy, convenience, and comfort of services;

  • compassion and kindness of care;

  • competence of providers to institute most appropriate evaluations and treatments, which would result in services that would result in the least risk to the patient and with the best health status outcome; and

  • administrative efficiencies of health care services that promote quality through effective communications, consumer and provider education, decision support, and quality management, treatment coordination, and other systems.

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