Although accreditation approaches and measurement of outcomes are central issues in ensuring the quality of managed behavioral health care systems, a range of other factors and approaches critically shape, affect, and address the quality of care. The unique structure of behavioral health care itself creates fundamental quality issues. Since most commercial insurance coverage is limited, commercially paid care is fragmented between primary and specialty sectors and there is a substantial public sector that serves as a safety net. Cost shifting and other relationships between sectors of care are in themselves a crucial problem. Furthermore, the complex framework for quality is itself a challenge for ensuring and improving quality.

As Table 2.2 illustrates, responsibility for quality is divided, and fundamental issues of coverage, benefit adequacy, and system design exert a profound effect on quality. For example, the typically limited behavioral health care benefits in most commercial insurance plans—especially in an environment of cost control—lead to a shift of consumers with high levels of need to the public sector. In the public sector, state-to-state variability in funding patterns, organization, and service adequacy lead to idiosyncratic patterns of care.

The array of approaches to monitoring service processes and outcomes is also complex. Responsibility for addressing quality is diffuse. Providers use their own measures and approaches to improve the quality of the care that they provide (e.g., quality assurance and continuous quality improvement). Thus, the responsibility for quality starts at the level of the providers.

Accrediting organizations (historically, especially JCAHO) have required providers to develop and implement internal quality assurance systems. Pressure to develop internal quality improvement activities may paradoxically be a positive result of external accreditation approaches.

States regulate health care practice by licensing individual practitioners, for example, physicians, nurses, psychologists, and social workers (see Table 4.1). Different states have different approaches to licensure, for example, whether so-