system's scope of responsibility for ensuring optimal psychological, cognitive, and environmental inputs to children's health status compared with the responsibilities of parents, communities, and the larger environment; and (3) the embryonic state of reliable and valid outcomes measures for services to children with chronic physical and mental conditions.

Broadly viewed, large knowledge gaps remain in evidence-based medical practice, in the health care industry's information systems, measures of children's health status, as well as in the nature and extent of relationships between children's health status, health care interventions, and other causal factors.

Policy Options to Improve Accountability

In addition to adequate data sources and measures of performance, meaningful accountability—in children's health and other areas—requires an adequate means of enforcing the performance obligations assumed by each relevant party. In the SCHIP program, relevant parties extend from DHHS to states to health plans to providers to enrollees and their families (IOM, 1998). General methods of enforcement of accountability in these relationships include the following:

  • setting minimum conditions for delegation of responsibility through contracting or other means, and
  • setting incentives based on performance.

Factors resulting in difficulties in enforcement include the following:

  • weaknesses in performance measurements,
  • insufficient resources to implement enforcement methods (e.g., inadequate state agency budgets for monitoring health plan performance),
  • failure to recognize enforcement methods,
  • lack of resources among Medicaid beneficiaries for filing a lawsuit,
  • failure to clearly specify enforcement methods in negotiations and/or contract language, and
  • failure to implement enforcement methods.

A variety of general policy options for improving accountability are available. These options are not mutually exclusive and can be implemented separately or in a coordinated way.

  • Continue to improve the scope and quality of performance measures and underlying data sources.
  • Recommend and/or regulate a specific approach to ensuring performance at each link in the chain between public and private funding sources and patients.

As states begin to develop their children's health insurance programs under the SCHIP program, they will be making many decisions. During the decision-making and implementation phases, the accountability systems that will be developed will need to be comprehensive, and efficient, with effective placement of responsibility and authority (IOM, 1998). These systems of accountability should focus on: ( 1) developing the information infrastructure and capacity to measure coverage (eligibility and enrollment, as well as sources of financing), access (utilization), and quality (technical customer satisfaction); and (2) integrating improved performance information into an approach for ensuring maximum levels of performance by every party on whom the health of American children depends.



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