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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH
The interest in quality is reinforced by consumer demand and empowerment, professional ethics, legal and regulatory interpretation of citizens ' rights, and attempts by businesses to satisfy and keep customers in a competitive health care marketplace. For public purchasers who are accountable for public funds, it is important to demonstrate that health care has good value and is worth the investment. The next section will give an overview of different methods for assessing quality.
One of the more traditional methods of quality assessment, accreditation of hospitals and managed care organizations, has evolved over the past 60 years to include highly specialized and involved accreditation of facilities, programs, and systems by numerous national accrediting entities, both voluntary and governmental. In addition, many managed behavioral health care organizations have developed “certification ” methods based on various quality parameters and sources to establish the qualifications of various institutional and professional providers that are contracted into their networks. Managed care accreditation has become increasingly popular for public- and private-sector health programs because it is viewed as the best current system for creating accountability and quality, even though there is limited evidence to support the relationship between adherence to quality standards and improvements in patients' health status. Accreditation will be discussed more fully in a later section of this chapter.
Professional Review of Care
Review of care by peers or other qualified health professionals has been practiced extensively, especially in professional case conferences and for granting credentials and privileges. Peer review has become more institutionalized, detailed, and systematically applied in recent years with the evolution of the utilization management and quality assurance movements. Concerns by payers, courts, and facilities about the medical appropriateness of care have led to broader applications of professional review to prospectively, concurrently, and retrospectively validate clinical decisions made by clinicians for individual patient care and care for populations of patients.
States have licensed physicians and nurses for many of the past 75 years through examinations and the recognition of professional training in accredited programs. Licensing has expanded substantially to other health care practitioners