private-sector purchasers of care are demanding that steps be taken to improve the quality and safety of health care (Galvin, 2001). Because of the enormous influence of the six major government health care programs within the U.S. health care sector as a whole, the committee expects that these programs will attempt to address quality issues first, and most effectively.


In this report, the committee responds to its charge by (a) describing the basic structure and beneficiary populations of the six major government health care programs, (b) documenting the activities of each of these programs with regard to the four principal components of quality enhancement identified above, and (c) offering recommendations for improving current quality enhancement processes.

Chapter 2 provides a description of each of the six government health care programs included in this study. It also reviews the broad trends affecting the needs and expectations of the programs’ beneficiaries, as well as key program features other than quality enhancement processes that affect the quality of health care provided.

Chapter 3 reviews the various roles played by the federal government in the health care arena and examines how these roles can be leveraged and better coordinated to improve the quality enhancement processes and activities of the various government health care programs. In general, each of the programs has fairly well-developed regulatory processes for ensuring quality, including minimum standards of participation for providers and external quality review activities. The federal government has far less experience as a value-based purchaser, although there are several notable examples of small-scale efforts to encourage disclosure of comparative quality data and selectively purchase from or provide payment incentives to high-quality providers. Lastly, three of the government programs—DOD TRICARE and the VHA and IHS programs—own and operate extensive delivery systems that have to varying degrees incorporated quality improvement activities into their operations.

Chapter 4 proposes a national quality enhancement strategy focused on performance measurement that is based on standardized measures of clinical quality and patient perceptions of care—two areas that have in recent years received increased emphasis from all six programs. There are important similarities in the types of measures and approaches adopted by the various programs. The chapter stresses the need to develop standardized measures that address important priority areas and the importance of applying these standardized measures across all the government programs. Also examined are some of the methodological and operational

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