quality performance goals. HCFA is requiring health plans, hospitals, and other providers to produce standardized quality reports, and state Medicaid programs are beginning to include quality provisions in their contracts with providers. The development of better standards and performance measures for cancer care could provide a way for large employers or groups of purchasers to exert influence on the quality of cancer and other health care.

A variety of mechanisms are being used to improve health care from the inside: total quality improvement initiatives, disease management programs, and implementation of clinical practice guidelines all have the potential to improve care. The experience with oncology practice guidelines has been mixed, with some examples of success but others of ineffectiveness in changing provider behavior or outcomes. Many guideline efforts have failed because of limitations in the way they were developed or implemented.

There are numerous health care accountability systems in place, but they fail to constitute a coordinated system for ensuring quality health care in general, and they do not yet embody a comprehensive, organized effort for cancer care. Given the diversity of the U.S. health care system, such fragmentation is not unexpected, but it could be remedied through a combination of public regulation and cooperation between public-and private-sector purchasers of care. Although much of the impetus for quality accountability has come from the private and professional sectors, government-sponsored programs have promoted public health accountability by maintaining cancer surveillance systems and monitoring the use of cancer screening tests among the U.S. population. The elderly are disproportionately affected by cancer, and cancer care quality indicators have in some areas been integrated into programs designed to ensure appropriate treatment for Medicare beneficiaries. The Agency for Health Care Policy and Research has assumed an important convening role in tracking clinical practice guidelines and supporting the basic health services research needed to form the basis of future guidelines.

Comprehensive improvements in health care quality and in the ability of consumers to make health care decisions that are fully informed on the basis of quality will likely occur only through collaborative efforts of the public and private sectors (President's Advisory Commission, 1998). As large health care purchasers, both sectors have a stake in improving the quality of care, and both sectors have knowledge and experience concerning quality measurement and reporting. Each sector has unique strengths. Private-sector organizations have the capacity to act quickly in response to rapid changes in the health care system. The public sector can provide established channels and safeguards to ensure representative action and open proceedings. Such an approach has recently been recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, and some initial steps have being taken to implement a public-private collaborative effort (President's Advisory Commission, 1998). A concerted public-private collaboration on the development and reporting of performance standards for cancer and other care could provide a framework for changing incentives in the system so that they aim at publicly accountable measures of quality.

References

The Advisory Board. 1998. The Oncology Roundtable. The Advisory Board Company, Washington D.C. American College of Surgeons. 1999. National Cancer Data Base: Future plans . http://www.facs.org



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