Quality Assurance in Managed Care and Behavioral Health


The health care delivery systems are faced with challenges of quality, costs, and access. The mode of addressing these issues lies in moderating them accordingly. The cost of health care affects the welfare of an economy adversely since individuals are not able to get the required medical care when they need it. The issue of access is also evident whereby the society is not accorded the care it needs due to bottlenecks in the system. Managed care is based on the objectives of cost reduction thus increasing access while at the same time enhancing the quality of health care provided. The managed care system in the United States has elicited both support and criticism as to its effect on the quality of health care. While some argue that managed care organizations are motivated by profit-making and focus on strategies to maintain a competitive advantage in the industry, others believe that through performance measures, quality has been increased. The discussions on quality assurance are diverse with some arguing that quality definition and measurement in managed care is subjective. However, most researchers and policymakers acknowledge that in cost reduction, quality always has to be accorded first priority.

Managed Care and Behavioral Health

Managed care forms part of the health delivery system of the US with programs based on reducing unnecessary health costs, increasing health benefits, and improving the quality of health care offered. Managed care makes use of various mechanisms to enable it to reduce health costs and increase quality. The mechanisms include offering incentives to patients and physicians in order to attract them to less costly systems, using programs that are specific to certain health conditions, cost-sharing means, reducing the time spent by patients through visits, and other incentives for enrollees who may be in need of surgery. Additionally, they use the advice and services of other providers of health (Haile & Stein, 2002). Managed care dates back to 1973 when the Health Maintenance Act was enacted with the health maintenance organizations pioneering managed care though it has been applied in the private sector as well.

Managed care is founded on system networks that are integrated to include managed care providers in order to provide health care to their enrollees and establish health standards. The techniques also involve quality improvement programs, educating patients accordingly, and through other initiatives for management of health, cases, and diseases (Noble & Klein, 2000). Managed care organizations (MCOs) provide managed care in a competitive health care environment with each organization operating as a unique business model. MCOs consist of physicians, other providers, and hospitals. MCOs have network-based programs such as health maintenance organizations, independent practice associations, and preferred provider associations among others.

The health care expenditure of the US has soared thus contrasting the aim of managed care and challenging its effectiveness. The supporters of managed care argue that it has increased access to health care and efficiency. Further, they assert that they have improved the standards of health care and provide clarification to the differences and relationship of quality of health care and the costs incurred. They assert that there is no consistency between costs of health care and quality and as such managed care does not provide poor quality of health care. The critics of managed care argue that the profit motive of managed care organizations leads them to base their strategies on cost reduction and hence less focus is placed on improvement of quality. Further, they observe that managed care organizations are biased on medical conditions and in urgent medical observation especially in mental health which they believe is due to the huge cost burden of mental illnesses. They further blame managed care for the increased cost of health care, insurance premiums, and the locking out of health care providers which they associate with lowered quality of health care (Haile & Stein, 2002).

Quality Assurance in Managed Care and Behavioral Health

Issues in Quality Assurance

The aspect of quality in health care acknowledges that the success of the health care delivery system is more effective in terms of quality improvement and access than in costs (Miller & Luft, 2002). The quality assessment in the competitive environment of health care raises issues of concern as to the clinical effectiveness or individual benefits. Quality measured in terms of professional judgments was possible in the traditional health care context. However, managed care poses a challenge of quality assessment since it is profit-oriented, expensive, and varies from medical outcomes, customer satisfaction and performance measurement indices, perspectives of stakeholders, and the influence of employers with the changed balance of power between the providers and purchasers of health care. The quality issue is also influenced by the competitive nature of the accrediting bodies of managed care and limited track records for quality decisions.

Ways in which Quality Assurance is upheld

The National Committee of Quality Assurance (NCQA) plays an important role in quality assurance in managed care. The organization carries out accreditation plans and another performance measurement. The accreditation plans mainly involve the review of operations of managed care organizations. It is usually done by NCQA reviewers including physicians and support staff who actually visit the managed care organization and develop plan evaluations in the areas of medical records, the credentials of the physicians, quality management, the rights and responsibilities of the members, utilization management, and preventive health services (Noble & Klein, 2000).

The plan also involves the use of medical services and examining the records for the assessment of the diagnosis accuracy, its appropriateness, consistency of care, and the preventive medicine offered. NCQA also develops performance measures such as the Health Employer Data and Information Set (HEDIS) most commonly applied. These measures include indicators covering the quality of care offered, level of access to it, satisfaction in the use of the care by customers and other stakeholders, the use of finances, management, and services (Haile & Stein, 2002).NCQA has plans to increase the performance indicators to cover the aspects of member satisfaction and health outcome (Noble & Klein, 2000). Other bodies involved in quality accreditations include the American Medical Association which plans on improving measures on the offices of the physicians, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in hospitals accreditation, the Foundation for Accountability, the Utilization Review Accreditation Commission, the Accreditation Association for Ambulatory Health Care and Medical Quality Commission among others. Accrediting bodies are faced with limitations of being effective to only large owned managed care organizations, challenges of technology, and the element of competition which does not allow for an individual accrediting body (Miller & Luft, 2002).


The aspects of quality are still relevant in the health care delivery system. This paper has reviewed the managed care organizations in the context of quality assurance. The issue raises both support and criticism and more discussion on the aspects of the quality definition, assessment, and application. It is evident that both the managed care organizations and the accrediting bodies are faced with the competition due to significant differences in the organizations hence limiting a universal application of quality in managed care.

Reference List

Haile, P., & Stein, M. (2002). Managed care incentives and inpatient complications. Journal of Economics and Management Strategy, 11(1), 37-79.

Miller, R., & Luft, S. (2002). HMO plan performance update: an analysis of the literature, 1997-2001. Health Affairs, 21(4), 63-86.

Noble, E., & Klein, L. (2000). Quality assurance: the measure of quality culture in a managed care setting. Total Quality Management and Business Excellence, 11(2), 199-205.

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