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you take. However, as I try to think about how it would play out and what impact it would have on the practice of medicine, I have some reservations.

It all comes down to changing the behavior of physicians. From what I know about the way physicians work and what motivates them. I am concerned that we may be trying to overstructure and overorganize the doctor-patient relationship. The interaction among provider institutions, medical professionals and patients must have a certain degree of autonomy and independence for things to work properly.

ECONOMIC ASPECTS OF QUALITY CONCERNS

Having said that, let me be a little more specific. I do not think that this report gives sufficient emphasis to the obvious historical fact that concern about quality, the whole quality agenda, comes basically from concern about cost. Yes, it is true that there has always been a concern about the incompetent or the impaired practitioner but basically the reason that the Congress asked the IOM to do this study was not so much worry about bad doctors or bad decisions, but about expensive doctors and expensive decisions. So this is first of all an economic issue. We ought to be paying more attention to economic solutions.

The two big problems are, first, the cost of our health care system, and second, the fact that we do not adequately identify, monitor, or prevent poor quality medical care.

The first problem of expense is mainly a problem of overuse. We have much more data—good hard information—about overuse being a big problem. I agree with Steven Schroeder (Schroeder, 1991) and his colleagues that underuse is also a problem, but we do not have any data on this. We have the uncomfortable feeling that underuse may be a problem because of the way prepaid health care is structured and the incentives that are involved in prepaid health care, but I do not think that this will turn out to be a major issue except when it comes to limited access. Underuse, as I see it, is mainly an access problem. It is true that we have the extraordinary example of Cody Howard, a child who had leukemia. His was the famous case in Oregon where the third party payer—Medicaid—decided not to provide a useful but high technology medical service, bone marrow transplantation. That is a dramatic headline-catching example of what may well be going on at a much lower technology level in prepaid health care arrangements. Nevertheless, I do not think that this dramatic example is as much a concern as the problem of people who have no insurance coverage who never get into the system at all. For them, the third party payer has no decision to make at all, because those people have no third party coverage.

So basically, overuse and underuse are economic problems. How do we deal with that? First, and foremost, we need more information about outcomes



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