A decade ago, economic problems were paramount in society in general and in health and mental health care in particular. Rising costs, especially striking in mental health care, helped fuel the rapid development of managed care and carveout managed behavioral health care organizations. There were temporary successes as health care costs were reduced in the 1990s, while our general economy boomed as well. But, again, as the general economy has slumped more recently, health care costs are rising dramatically.

What was unclear in the past decade was how this economic emphasis affected quality. In society in general, it was not clear that an improved economy actually improved quality of life across the board, especially in those increasing numbers of families with two parents working full time (with less time for their children) and for those poorest pockets of society that were untouched by the economic boom. In health care and mental health care, there certainly is no evidence, or some anecdotal information to the contrary, that quality of care was improved under managed care.

Perhaps quality is where more attention is needed, both in society and health care. Irrespective of managed care, data have indicated that about 30% of health care is unnecessary and another 30% insufficient (Becher and Chassin, 2001). In addition, there seems to be wide variation among practitioners and locations, and a tendency for poorer treatment to be received by those who are poor and of a minority ethnic background. The results for mental health care in particular seem no better (Lehman, 2001). Anyone who has done a significant amount of utilization review of community practice would probably agree with these conclusions (Mohl, 1996).

Would any of us find these figures acceptable? If not, we have work to do to improve our quality of care. In our field, our responsibility for this endeavor takes on extra weight due to the very nature of the problems we encounter. Given that our patients have significant problems in their thinking, emotional responsiveness, behavior and even reality testing, it would be a cruel irony to rely solely on their subjective sense of being well-served by their treatment. Patient satisfaction, therefore, can be affected by a variety of factors and should only be part of an assessment of quality of care.

Our own subjective assessment of patient improvement also has significant limitations. Normal professional narcissism and countertransference may impair our assessment of our own success with patients.

We all need to do more, as individual practitioners, as managed behavioral health care organizations (MBHOs) and professional organizations. Whereas there is not much indication that private practices are trying to measure quality, several large health maintenance organizations are indeed rewarding practitioners for documented quality of care (Freudenheim, 2001). Although long-term data were sparse, HMOs are assuming that more prevention and improved quality would be doable and, although costly to do, would save more money by preventing more expensive treatment (Mason et al., 2001). The possibilities are many. Among them, in our individual work with patients, are: