Managing Managed Care: Quality Improvement in Behavioral Health

The 1990s witnessed the emergence of managed care initiatives to control reimbursement rates and utilization rates and foster competition as the dominant strategy to control health care costs (1). By 1997 more than 80 percent of American workers and 40 percent of Medicaid recipients were enrolled in managed care plans (2).

This report from the Institute of Medicine provides managed behavioral health care consumers and providers with a guide "to the development, use, and evaluation of performance indicators, accreditation standards, and quality improvement mechanisms" that should foster the purchase and delivery of quality services and benefits in a cost-effective and efficient manner.

To help achieve these goals, the Institute of Medicine draws on its earlier definition of quality of care as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (3). It adapts as its conceptual framework Donabedian's paradigm (4) to understand and measure quality, which describes the interrelationship between structure (resources and capacity of the delivery system), process (procedures for the delivery of care), and outcome (the results of care).

Using this conceptual framework, the report presents findings and recommendations in 12 areas: structure and finance, accreditation, consumer involvement, cultural competence, special populations, research, the workplace, wraparound services, children and adolescents, clinical practice guidelines, primary care, and ethical concerns.

The report's section on cultural competence exemplifies how its findings and recommendations are aimed at standardizing services as well as measuring performance compliance within managed behavioral health care organizations. For instance, the report recognizes the existence of barriers to obtaining culturally appropriate behavioral health care for racial and ethnic minorities, and it recommends that providers become culturally competent. This latter goal is to be achieved by providers' developing cultural sensitivity plus the knowledge and skills that meet the needs of patients from diverse cultural backgrounds.

Measures of performance compliance within this domain include using either a multilingual staff or interpreters, incorporating awareness of cultural factors in history taking and diagnosis, and changing communication patterns to recognize cultural beliefs, practices, and roles. Achieving cultural competence would help to provide effective clinical care to patients from a particular ethnic or racial group.

This book is on the cutting edge of managed care policy and program development. It fosters a greater understanding of the process for developing and evaluating managed behavioral health care programs. The report's guidelines are designed to create a responsive behavioral health care system that, while using cost controls and best practices, would be both efficient and effective.

Mr. Korotkin is coordinator of the office of services to special populations of the New York City Department of Mental Health, Mental Retardation, and Alcoholism Services and is on the adjunct faculty of Montclair State University in Montclair, New Jersey.