tages and disadvantages of a new system so that its realization can be in some ways self-correcting.


The nation is generally perceived to have a solid, admirable base of good quality health care, and the elderly are usually satisfied with the quality of care they personally receive. Contrasting with this positive perception of the overall quality of care in the nation is a large body of literature that documents areas of deficiencies in all parts of the health sector. Some of these relate to overuse of unnecessary and inappropriate services, some to underuse of needed services, and some to inadequate technical skills, poor interpersonal care, or faulty judgment in the delivery of appropriate services.

The committee concluded that significant problems exist in quality of care and in our present approaches to quality assurance. The problems are sufficient to justify a major redirection for quality assurance in this country and, in particular, a more comprehensive strategy for quality assurance in Medicare.

Our major findings and conclusions include the following:

  • A quality assurance program should be guided by a clear definition of quality of care.

  • No single approach or conceptual framework to quality assurance is likely to suit all purposes.

  • Regarding the elderly,

  • the elderly population continues to grow, both in absolute numbers and as a proportion of the entire population,

  • the average number of years lived after age 65 continues to increase, and

  • an increasing number of people in this population live with chronic illness and disabling conditions.

  • Regarding Medicare and the elderly,

  • health care costs continue to rise,

  • pressures for cost containment increase, and

  • use of sites of care other than inpatient (i.e., outpatient and long-term-care facilities and home settings) continues to expand.

  • Near universal coverage of the elderly population by the Medicare program gives them better access to health care than any other age group; nevertheless, gaps in coverage and financial barriers do exist and adversely affect quality.

  • Regarding the burden of poor quality,

  • evidence of overuse of health services is substantial,

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