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with the comments in the summary of the committee's report about the need to build on and strengthen the existing PRO infrastructure for quality assurance. The criticisms noted in the summary on the PRO program are all appropriate, but I am not going to blame the individual PRO organizations for that. We in the Congress structured the program poorly and we, along with the Health Care Financing Administration, were negligent in attending to essential details. For example, we did not provide space for the individual PROs to breathe, grow, and adjust to reality at an individual state level as I intended when we first started the program. Thus, we now have a structure that gives primary attention to utilization rather than quality, focuses on outliers rather than the average provider, concentrates on inpatient care, imposes excessive burdens on providers, and does not use positive incentives to alter performance. It follows, of course, that almost every doctor perceives the program as adversarial and punitive.

For the last five years or so, we have listened to similar complaints about the PROs without doing anything to correct the problems. The IOM critique is an accurate critique. Furthermore, the committee's conclusion to build on the infrastructure that is in place—to learn from what we know—is also an appropriate conclusion.

I do not consider it my task today to comment in depth on the specifics of the 10-year implementation plan. I would like to make a general comment, however. The IOM and the study committee are to be complimented on the repeated emphasis in the implementation plan on the engagement of providers, patients, and consumers in quality assurance. That theme is present throughout the report. I agree with the importance of keeping the lines of communication and understanding open.

ADDRESSING PROBLEMS OF UNDERUSE

Problems of access and underuse are quality-of-care issues. However, the IOM was not charged by Congress through this study to focus on those problems. Thus, it is not a surprise that the report does not give equal attention to quality issues of the uninsured or underserved. Congress requested that the IOM undertake this study because of concern about the quality assurance program of Medicare—thinking in particular of the existing PRO program, which only monitors the quality of care provided or delivered to the Medicare beneficiary. The study was also supported by members of Congress who acknowledge that a price is paid for achieving advances in medicine: paying for new medical technology means less is available for the uninsured or underserved. We felt that we first needed to know how to assure the quality of care that is delivered; we needed to know how to determine if and where we are spending more than is necessary to have quality care.



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