community, referred to as community benefit in qualifying for nonprofit tax status, are another commonly missing element.

Workshop participants commented that indicators generally do not address age-related aspects of health for the young and the old. Also missed is the intergenerational impact of health problems (e.g., parents caring for children or adult children caring for aging parents). Environmental health determinants need attention as well. Also raised was the idea of performance indicators for employers, both for care provided at the worksite and for work-related health problems such as injuries or pollution. Such indicators would require careful definition of the population or community to which they apply.

The discussion drew attention to the lack of data on the effectiveness of many health services and the problem that it can create for selecting performance indicators. Another challenge is determining appropriate indicators for multidimensional health issues. Where the determinants of health are not adequately understood, it may be necessary to turn to indicators for performance in areas such as service capacity or processes of care. Some users may find those indicators less satisfactory. For example, employers evaluating health plans may care more about enrollee quit rates for smoking than the availability of smoking cessation programs.

Issues related to accountability generated much discussion. 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. Health plans can, for example, make valuable contributions by responding to known concerns (e.g., smoking) and by identifying community-based problems (e.g., toxic exposures) through the need they create for health care services. Health plans could also benefit from community-based health assessments that generate information about factors affecting the health—and health care needs —of their members.

The question of how to “operationalize” health plan accountability was raised. Currently, employers are a principal locus of oversight and influence. It is not clear whether the plan selections made by individual consumers are an adequate mechanism to enforce accountability. Regulatory requirements for health plan performance are possible but may not be the most acceptable approach. In response to a question, it was suggested that performance monitoring efforts have given little attention to understanding the readiness or capacity of health plans to make changes to respond to community health needs or to meet broader population-based expectations for accountability.

The observation was made that while some plans are willing to accept limited responsibility for elements of community health many are not ready to do so. A more acceptable alternative to holding health plans accountable for

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