A review by the Center for the Advancement of Health and the Western Consortium for Public Health (1995) of many activities in the public and private sectors to develop and use performance indicators examined the extent to which the indicators addressed a range of consumer and community health concerns. They found a focus on the performance of individual providers and the use of health services. With programs such as the Health Plan Employer Data and Information Set (HEDIS), which the National Committee for Quality Assurance (NCQA, 1993) now sponsors, measures are moving beyond users of health services to entire enrolled populations in managed care plans.
Several "gaps" were noted among the indicators that were reviewed, including individuals' functional status, health-related quality of life, and behavioral and psychosocial aspects of illness and health care. Mental health and substance abuse services receive some attention, but they are often provided by separate specialty groups, making it difficult to identify problems in integrating psychosocial services with other forms of care. Determining appropriate indicators for multidimensional health problems is also a concern.
Regarding accountability, one concern is reaching agreement among stakeholders on where accountability for health outcomes can and should lie. In particular, the role that private sector health plans (and other medical care providers) should be expected to play in community-based health improvement efforts is a source of concern and debate. Currently, employers are a principal locus of oversight and influence in "operationalizing" accountability. It is not clear whether the plan selections made by individual consumers will have sufficient impact. Regulatory requirements are possible but may not be optimal. Some health plans are willing to accept limited responsibility for elements of community health but others may not yet be ready to so.
Federal, state, and local public health agencies have special responsibilities for protecting and improving community health. The Future of Public Health (IOM, 1988) defined their core functions as assessment of health status and health needs, policy development, and assurance that necessary health services are