chaser of health care services. The means of determining the impact of financial incentives and identifying the amount and structure of payment necessary to effect change remain largely unexplored at the national level, notwithstanding a body of experience at the state level that could inform such research (Kaye and Bailit, 1999). Research is needed to develop different models of compensation (including criteria for qualifying for higher payment) and to test the models to determine whether such strategies actually change performance and outcomes.

The Rewarding Results initiative announced by the Robert Wood Johnson Foundation and AHRQ in early 2002 serves as an example of research designed to explore strategies for creating incentives to improve quality. It provides grants and technical assistance to purchasers and health plans to develop incentive structures that “align incentives with high quality care” (National Health Care Purchasing Institute, 2002). As discussed above, QuIC, in collaboration with other agencies, can identify those programs best suited to such a demonstration that would yield important information for policy makers across the various programs. AHRQ should devote increased attention to the evaluation of alternative options for building incentives to improve quality into payment systems.

Access to Information for Informed Decision Making

Evaluation and testing play a particularly important role in determining the best strategies for providing public access to comparative quality information targeting information for different users to ensure the most beneficial impact. While there is substantial activity directed at exploring various approaches to public access, experience and reliable knowledge are limited. Accordingly, this remains a somewhat experimental area, one that will be susceptible to modification and innovation as understanding increases.

Existing evidence indicates that consumers generally rely on comparative quality data only to a limited extent and make choices that do not necessarily correspond to their stated preferences (Hibbard and Jewett, 1996; Hibbard et al., 2001). Studies show that this lack of reliance stems from a lack of understanding or distrust of performance ratings and their perceived lack of relevance or utility (Vaiana and McGlynn, 2002). This conclusion is confirmed by experience with disclosure of comparative quality data on hospitals and health plans (Jencks, 2000; Schneider and Epstein, 1996). In the latter two examples, publicly disclosed data showing variations in the quality of care and patient outcomes have had little impact on consumer choice or health plan contracting with hospitals (Jencks, 2000; Schneider and Lieberman, 2001).

Current research efforts focus on developing presentations of com-



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