Native Americans, the federal government can serve as a model for all aspects of health care organization and delivery. The federal government also provides support for applied health services research, much of which directly enhances the government’s ability to carry out effectively its roles as regulator, purchaser, and health care provider.

In the government health care programs that provide care through the private sector—Medicare, Medicaid, SCHIP, and to some degree DOD TRICARE—the federal government has relied primarily on regulatory approaches to promote quality. Regulatory approaches are best suited to establishing a “floor” that protects beneficiaries from providers lacking basic competencies. When it comes to encouraging providers to pursue higher standards of excellence, the regulatory approach is a blunt tool that generally fails to differentiate among grades of quality.

Purchasing strategies are aimed at raising the quality of care offered by the majority of providers. Such strategies include the provision of financial and other rewards (e.g., higher fees, Diagnosis Related Group [DRG] payments, or bonuses) to providers and health plans achieving high levels of quality. The disclosure of comparative performance data on providers and health plans draws attention to best practices in the hope of driving patient volume to the higher-quality performers, and spurring action on the part of poor and average performers to enhance their knowledge and skills or limit their scope of practice. The public disclosure of quality and safety information may also encourage professional societies, board certifying and accrediting entities, and other leadership organizations to take action to achieve broader adherence to defined standards of care.

In its provider role, the federal government assumes all the responsibilities of ownership of health care institutions, employment of the health care workforce, and management and operation of comprehensive delivery systems. In this capacity, it has an opportunity to serve as a laboratory for the testing of new financing, delivery, and information dissemination models while experimenting with various quality measurement and improvement strategies. The three government programs that provide services directly—the VHA, DOD TRICARE, and IHS programs—have led the way in building clinical information systems to support care delivery, quality improvement, surveillance and monitoring, and many other applications. Since taxpayer dollars have financed the development of these systems, more should be done to facilitate their application in other parts of the health care system.

As a major sponsor of applied health services research, the federal government provides support for the development of knowledge and the creation of tools needed to carry out more effectively the roles of regulator, purchaser, and health care provider. Through AHRQ and other ap-

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