admission data collected by managed care organizations. These rates do not reflect outcomes well because they are confounded, for example, by issues related to access and by the dropping of clients from insurance plans.

The outcomes field would be improved significantly by developing standardized data that are publicly available. To accomplish this, it is necessary to move away from the focus on client satisfaction-based indicators of outcome to clinically-based indicators of outcome. This is not an easy transition to make. Client satisfaction indicators are easier to develop and to collect than are clinical indicators of outcomes, for reasons that are discussed throughout this chapter. Ideally, the steps should include clinical efficacy trials and then health services effectiveness trials, followed by comparisons of different practice settings, case mix adjustments, and so forth, for the assessment of outcomes in managed care settings. The assessments of outcomes could then become public information, through report cards or through other means.

As the treatment field moves in the direction of accountability for outcomes within programs, several difficult issues need to be addressed. The first has to do with external versus internal monitoring of treatment outcomes. External monitoring brings with it a higher potential for standardization across programs, the input of those with expertise in methodologies, and the credibility that comes from independent evaluations. Internal monitoring lacks those particular strengths, but offers the ability to collect the precise kinds of data most useful to managed care organizations in improving their particular programs.

A second issue has to do with finding valid measures for outcomes and requiring their collection by programs. Ongoing collaboration between outcomes researchers and clinicians can promote the further development of such measures