addressed by the payment incentives report in this Pathways series (see Chapter 1).

In short, the committee concludes that measurement of the health care delivery system should not be impeded by the impossibility of first identifying an accountable actor or the perception that responsibility for care is outside one’s realm of control. Indeed, one valuable and intended effect of the integrated measurement system proposed by the committee could be to induce new parties to assume such responsibility. This position represents a significant break from commonly accepted criteria for performance measurement.


To this point, the discussion has focused primarily on insights that emerged from the committee’s review of currently available performance measures and an analysis of the quality of these measures against the goals and aims of health care measurement. The committee’s primary charge was to recommend a subset of measures—derived from leading performance measure sets—that could be used to align performance with payment under the Medicare program. The committee addressed this task within a more general framework designed to move the U.S. health care system toward the overarching goals discussed earlier. Its ultimate objective was the creation of a measure set that would be consistent both with the goals and aims for health care improvement set forth earlier in this chapter and with the 10 design principles for performance measurement articulated in Chapter 2. The resulting measures encompass what we need to know about health care quality to guide future payment policies and practices.

Criteria for Selection

In addition to the 10 design principles articulated in Chapter 2, the committee identified criteria to guide the selection of specific measures. The criteria in Box 4-3 apply to individual characteristics of either a specific measure (e.g., validity and reliability) or the collective measure set (e.g., comprehensiveness). Other groups have articulated these criteria: measures should be scientifically sound, feasible, important, aligned with other leading measure sets, and comprehensive. However, it is important to point out the absence of one criterion often used by other groups: that a measure be within the control of an identifiable actor. As discussed above, the committee takes the position that improvement across many important domains of care will require action by multiple parties—including patients, providers, and other stakeholders (such as health plans, payers, and public health agencies), and the committee therefore endorses public reporting on measures, such as longitudinal care, that foster shared accountability.

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