Robert B. Copeland

As the Institute of Medicine committee worked on a strategy for quality assurance in Medicare, my role was to offer perspectives from patients and providers at the primary care level. During this time, I had personal experiences with the new Medicare utilization review contractor in Georgia. This provided a dramatic example of how well-intended, but flawed and counterproductive, reviews of patient care services can be. For the past 17 months, Georgia has had utilization review by a for-profit company as mandated by the Health Care Financing Administration. The company was freed from many of the constraints of previous review programs. This unique experiment has decreased Medicare expenditures largely by rationing primary care services. This new plan's long-term negative effects on quality of care, access of Medicare enrollees to primary care physicians, and career decisions for primary care providers are far more significant than any short-term savings.

I mention this experience now to reinforce what we all must respect as we look at new strategies for Medicare quality assurance. That is, there is a critical need for broad reform that is data based, that takes a long-term view, and that will constructively remodel, not remuddle, assessment of quality in Medicare.

This part of the conference proceedings discusses another of the new directions that our committee identified as specific strategies—improved decisionmaking by physicians and patients. This is both an important and an obtainable goal. Aspects of those issues are discussed by two outstanding speakers. Paul F. Griner presents the committee's views on physician and patient decisionmaking, bringing to his paper the special perspectives of a clinician, hospital director, and medical educator. John Rother, the Director of the Legislative and Public Policy Division at the American Association of Retired Persons, provides the outside response, reflecting the orientation of a major patient-and population-oriented organization.