provide more direct input into the development of accreditation and other assessment strategies.

Federal, state, and local governments, accreditation organizations, managed care organizations, purchaser coalitions, consumers groups, professional organizations, and the media are actively involved in quality assessment. Some of these efforts are collaborative, but some are competitive. Overall, the picture is incomplete, inconsistent, and inadequate for making truly informed health care purchasing decisions. To those who are responsible for purchasing care, the absence of consensus on quality measurements is a challenge.

The committee developed a set of findings and recommendations in 12 areas: structure and financing; accreditation; consumer involvement; cultural competence; special populations; research; workplace; wraparound services; children and adolescents; clinical practice guidelines; primary care; and ethical concerns. Chapter 8 of this report contains all of the findings and recommendations. Only the recommendations are presented in this Summary.

1.1 The reform of systems of care financed by states and counties must: (1) recognize current aspects of private health care in those states and counties and (2) consider the design and development of mechanisms to inhibit cost-shifting.

1.2 Payment arrangements that reduce incentives to underserve individuals with behavioral health conditions should be encouraged.

1.3 The reform of state and local systems through the use of managed care should incorporate a recognition of and responsiveness to the unique needs of consumers served by public systems.

1.4 Accreditation organizations, when appropriate, and purchasers should develop criteria and guidelines that: (1) recognize and measure dumping, skimming, and cost-shifting; and (2) specify rewards for organizations, groups, and individuals that provide appropriate care and penalties for those that do not.

1.5 Purchasers should ensure continuity of care for consumers when managed care contracts are awarded to different provider organizations.