Assuring Quality in Proprietary Managed Care Systems

Abstract

This paper defines quality assurance (QA) and dis cusses state-of-the art QA programs in managed care organizations today. Utilization management (UM) is distinguished from QA, although they are interre lated. While UM is process-oriented and focuses on efficiency and cost-effectiveness, QA is directed more to the result or outcome of medical care. The major abstracts in the transition from process to outcome- oriented QA are agreed upon standards of care and data systems. The medical profession would seem a logical candidate to develop these systems, but the profession has resisted such efforts, showing an ina bility to enforce true accountability. The impact of QA/UM on clinical decision-making is discussed, with implications for the profession of medicine.