approaches—public disclosure of performance data, payment policies, and performance improvement processes—can all provide strong incentives for change to providers (both clinicians and institutions), purchasers, and beneficiaries. Yet to do so, all three approaches depend upon the availability of accurate, reliable, and valid performance measures. These measures can serve as the foundation for public reporting programs intended to promote accountability among providers and aid consumers in making informed choices. They can also provide the basis for initiatives that create incentives for providers to deliver more effective and efficient care. Public disclosure and payment policies are then presumed to work in tandem to motivate quality improvement efforts that affect the actual processes of care delivery. However, such synchronicity is not always achieved, and as a result, potential improvements are not fully realized.

Taken together, these three approaches offer a continuum of options for influencing provider and patient behaviors in ways that can produce improvements in health and health care. For example, diabetic patients who receive care from multiple providers in numerous settings often fail to receive services from which they would likely benefit, such as testing for hemoglobin A1c and cholesterol levels. Measuring these processes can reveal such shortcomings and thereby result in better-quality care and improved health outcomes (Harris Interactive, 2001). Potential options for addressing such failures and ensuring they are not continued include (1) bonus payments to primary care providers whose performance profiles indicate high levels of compliance with practice guidelines (a payment policy option); (2) disclosure of comparative performance reports on providers to assist consumers in selecting the highest-quality providers (a public disclosure option); (3) reduced levels of regulatory burden for primary care providers with exemplary performance (a performance improvement option); and (4) the establishment of communitywide diabetes registries by Medicare’s QIOs to assist all providers in monitoring beneficiaries’ receipt of effective services (a performance improvement option).

To drive change in the status quo of measurement, all such levers should reinforce achievement of the six aims of the Quality Chasm report cited earlier—safe, effective, patient-centered, timely, efficient, and equitable care. Together, the effects of multiple changes at different levels of the health care system—patient and community, microsystem, organizational context, and environmental context—must be sufficient to encourage and enable payers, providers, and patients to close the quality gap (IOM, 2001).

Although performance data are integral to the success of efforts targeting public disclosure of performance data, payment policies, and performance improvement processes, currently available performance data on many types of providers are quite limited. Most performance measurement projects to date have relied on a small set of technical quality measures (i.e., medical care process measures) derived from administrative data produced



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