The federal government plays a number of different roles in the American health care arena, including regulator; purchaser of care; provider of health care services; and sponsor of applied research, demonstrations, and education and training programs for health care professionals. Each of these roles can support the accomplishment of somewhat different objectives along the spectrum from quality assurance to quality improvement to quality innovation.

As discussed in Chapter 1, research demonstrates wide variability in the quality of health care. As illustrated in Figure 3-1, some proportion of care is poor and unsafe; no patient should be exposed to this care. Some care is adequate, but not as good as it should be. Most of the services received by patients are effective, but the benefits are not as great as they could be, and resource use is unnecessarily high. Some fraction of patients receive very good care that is consistent with best practices, and an even smaller fraction probably receives excellent care employing state-of-the-art practices. Efforts to improve quality seek to shift the curve to the right and to truncate the left tail of the distribution.

It is through its regulator role that the federal government establishes minimal health care standards. Effective regulatory requirements protect beneficiaries from incompetent, impaired, and inadequately trained clinicians and from health care organizations that lack the requisite capabilities and processes to provide a minimal level of quality. Although regulatory “floors” can continually be raised, thus tightening the distribution of services by quality, regulatory approaches most often seek to cull substandard providers—to truncate the left tail of the distribution. Regulatory requirements have generally been set at levels that nearly all providers could satisfy. Regulatory requirements can have adverse impacts as well, by creating unnecessary reporting burdens, conveying conflicting objectives, and omitting essential elements of quality.

FIGURE 3-1 Distribution of care by level of quality, a conceptual scheme.

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