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Medicare: A Strategy for Quality Assurance - Volume I
care industry. These range from licensing professionals and certifying facilities (mainly with the intent of assuring at least a minimal level of quality) to controlling expansion of providers and services through health planning and certificate of need, invoking explicit cost and utilization controls, and mandating quality assurance efforts in the publicly financed health programs. Other public policy efforts directed toward improving access to quality care include programs such as educational assistance for residency training programs and the National Health Service Corps to improve the distribution of providers. The responsibility of the Health Care Financing Administration (HCFA) for the quality of care rendered to Medicare beneficiaries is fundamentally a regulatory issue, although in recent years quality assurance activities have taken on a competitive marketplace orientation.
The health care industry is among the most regulated industries in this country. According to Vladeck (1988, p. 100), “Concern…for the quality of health care services has led to external controls in the United States that are more extensive, more intrusive, and more complex than they are elsewhere in the world.” None of these regulatory controls has provided a completely satisfactory approach to assuring the quality of health care in this country, yet none has ever been completely abandoned, for reasons partly related to the “public good” aspects of health care.
Health Care as a Public Good
Perhaps more important than the actual (and extensive) involvement of governmental bodies in health care is the perception of health care as a public responsibility, indeed, a public good.11 Members of our society widely believe that an adequate level of medical care should be available to the poor and elderly, if not all citizens (Enthoven, 1988; Estes, 1988; Fuchs, 1988; Goldsmith, 1988; Arnold, 1989; Leader and Moon, 1989).
One simple aspect of health care as a public good is the gathering and dissemination of information. In the case of quality assurance, this includes information about the effectiveness and appropriateness of medical practices. As stated by Roper et al. (1988, p. 1197), “the benefit of better information accrues to the public at large, not just to those collecting it, [and] the market system may not ensure adequate investment in the necessary research and data collection.”
The rationale of viewing health care as a public good, although not a Constitution-backed entitlement or right, is similar to the thinking behind any other public good. The health of individuals affects the health of the community at large; clear distinctions are not easily made between public health and private medicine. Changes in the health status of the community have a domino effect on various sectors of our society and economy.