Fifth, the IOM committee recommends that HCFA retain its role of preventing harm to patients from providers who are not maintaining acceptable standards of quality. The PRO evidence suggests that a relatively small number of physicians contribute disproportionately to problems in overuse, underuse, and poor technical quality. The Harvard Medical Practice Study suggests that the same is true for hospitals. Incompetent providers should receive special attention. The challenge for the federal government is for all its agencies that become involved with seriously substandard providers to cooperate with one another.

The evidence from the IOM report is clear: there is a need to ''manage for quality'' in the Medicare program. It justifies a major increase in effort in the next decade.

Chassin, M.R., Kosecoff, J., Winslow, C.M., et al. Does Inappropriate Use Explain Geographic Variations in the Use of Health Care Services? A Study of Three Procedures. Journal of the American Medical Association 258:2533-2537, 1987.

Harvard Medical Practice Study. Patients, Doctors, and Lawyers: Medical Injury, Malpractice Litigation, and Patient Compensation in New York. The report of the Harvard Medical Practice Study to the State of New York, 1990.

Hsiao, W.C., Brown, P., Yntema, D., et al. Estimating Physicians' Work for a Resource-Based Relative Value Scale. New England Journal of Medicine 319:835-841, 1988.

Institute of Medicine. Medicare: A Strategy for Quality Assurance. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990. (See especially Volume I, Chapter 7.)

Leape, L.L., Park, R.E., Solomon, D.H., et al. Does Inappropriate Use Explain Small-Area Variations in the Use of Health Care Services? Journal of the American Medical Association 263:669-672, 1990.

Mills, D.H., ed. California Medical Association and California Hospital Association. Report on the Medical Insurance Feasibility Study. San Francisco, Calif.: Sutter, 1977.

Morford, T.G. An Administration Response to the Institute of Medicine Report From the Health Care Financing Administration. Pp. 179-185 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.