quality assurance structure in an effort to harness the forces of professionalism, competition, and malpractice in a more mutually supportive way.15 Some malpractice insurers also offer incentives in the form of lower premiums for organizations that have an effective risk management program in place (GAO, 1989).

Value Purchasing

Perhaps more a hybrid than a separate and unique force are the joint efforts of purchasers, providers, and consumers to promote the idea of value or quality within the context of cost.16 As the environment for health care delivery has become more competitive, the call for accountability in both the economic and quality spheres is dispersed among many more parties than was true a decade or two ago. Providers see the responsibility for quality assurance shifting away from them and a growing involvement by purchasers and consumers. By contrast, providers and consumers (frequently through unions) are assuming some of the responsibility for cost containment heretofore assumed by private third-party payers, by employers, and, in the case of Medicare, by the federal government. Coalitions developing between payers and capitated prepayment health care systems are attempting to promote quality and contain cost. The need for large corporations and self-insured groups to reduce their health care expenditures while retaining some confidence that quality of care will not be harmed may produce an impetus for quality assurance that will far exceed the pressures already discussed.

Successful value purchasing depends on access to useful information; inability to judge the reliability, validity, or relevance of available information on quality of care limits the potential of value purchasing. The movement toward population-based outcome measurements may help address some of these problems.

Decision Making and Population-Based Outcomes

Utilization management, practice guidelines, more competition, more regulation in health care, and so forth can all be seen as manifestations of a perceived need for better decision making on the part of purchasers, providers, and patients. Interest and research in population-based outcomes and the potential use of such measures in improving decision making have increased (Tarlov et al., 1989). One very significant dimension to current research into patient outcomes is patient preferences and values (sometimes denoted “utilities”); this links the patient-provider decision-making process with outcome measures (Greenfield, 1988).

Informed decision making involves numerous parties with different ca-

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