A challenge for quality assurance is to assess, monitor, and regulate mental health and substance abuse care in primary care settings. This is a pervasive problem, given the high percentage of mental health and substance abuse care provided in these settings, but the breadth of the issue is tempered by the fact that there may be less risk of serious problems in this arena, in that many patients whose mental health and substance abuse problems are treated in primary care settings are less ill or disabled (IOM, 1996). On the other hand, failure to recognize or appropriately treat a mild depression or dysthymia, for example, may have modest short-term consequences but may also fail to prevent an otherwise unnecessary escalation of the illness into severe depression.

The challenges in monitoring behavioral health care in primary care settings are magnified by the increased scope and complexity of the health conditions that are expected to be treated in the primary care settings, the wide variability in the extent of psychiatric training received by family physicians and other primary care practitioners, and the rapid development of new treatments that makes it increasingly difficult for practitioners to stay current. However, as a matter of policy, the committee agrees with the IOM Committee on the Future of Primary Care and its recommendation to develop and evaluate collaborative care models with primary care clinicians and behavioral health professionals (IOM, 1996).

Many challenges are related to measuring, ensuring, and improving the quality of care in specialty settings and, especially, in managed behavioral health care settings. The field of managed behavioral health care is new, diverse, and highly competitive. Therefore, it is not regulated as intensively as more traditional forms of managed care. For example, both the federal government and the states regu-