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MANAGING MANAGED CARE: QUALITY IMPROVEMENT IN BEHAVIORAL HEALTH
ate mental health and substance abuse care (NCQA, 1996a, b). For example, new admissions for mental health problems can be misinterpreted as readmissions for substance abuse if there had been an earlier substance abuse treatment episode. Finally, the lack of data on patient characteristics means case mix adjustments may not be feasible and makes it difficult to assess biases in patterns of care and the need for culturally and gender-specific services.
Despite these limitations, administrative data sets are an efficient and important source of information for the assessment of quality of services. Program managers, program evaluators, and consumers, however, must be aware of the potential problems and biases and include an assessment of a data set's limitations in the analyses of services and the conclusions about quality. It is also critical to assess the potential for combining information from commercial and public administrative data systems so that the nature and extent of out-of-plan utilization can be assessed and added to the evaluation of the quality of care.
If you give information to providers and you work with information systems with the goal of providing information in real time, then quality assurance initiatives can be transformed from an external administrative burden into a powerful tool for improving clinical practice and increasing efficiency.
American Psychological Association
Public Workshop, April 18, 1996, Washington, DC
ROLE OF GOVERNMENT IN QUALITY ASSURANCE
Historically, the federal government's involvement in quality review and accreditation has been indirect. For example, in the area of hospital accreditation, the federal government has typically given an accreditation organization such as JCAHO deemed status. This means that the federal government makes use of the information collected by JCAHO and relies on JCAHO's judgments regarding the quality of hospitals in setting eligibility rules for reimbursement by Medicare.
States also are beginning to review and update traditional regulatory and contracting practices and to develop arrangements for deemed status. For example, COA holds deemed status in 22 states that recognize the COA accreditation process in lieu of Medicaid certification, state monitoring, or licensing (COA, 1996c).