Government has been, of course, the largest single player in this arena, and as its obligations for ensuring access to care have grown, so also have its concerns for the cost of care, its quality, and for a balance of the two. Consequently, as government has had to assess the performance of its programs, to discover their weaknesses, and to find remedies for these, it has repeatedly called on the IOM for help. Because good policy requires good information, the Institute has perhaps made its greatest contribution as a source of impartial expertise whenever called upon for investigation, analysis, and advice.

Delivering care and paying for it under organized auspices, governmental and other, have improved access to care for many (though not all), while also offering prospects of significant improvements in quality as care is stripped of superfluities and becomes more subject to institutional supervision and public scrutiny. At the same time, payment per case and per capita, as well as, perhaps, the resurgence of for-profit enterprise, may have posed a risk to consumers. On the one hand, as efforts to control costs gain dominance, there is a temptation to skimp on some important aspects of care, of which attention to the niceties of care, so cherished by consumers, is perhaps the most vulnerable. On the other hand, as care is shifted to less equipped, less supervised sites, the threat to quality is bound to grow unless special efforts are made to anticipate the danger.

Consumers, individually and in association, have reacted rather incoherently to these developments. Some have become so disenchanted with the medical establishment, so suspicious of its motives, so skeptical about the efficacy of its methods that, alienated, they have sought alternatives apparently more responsive to their needs. Others, sometimes expecting more of the medical system than it can realistically accomplish, have challenged it by demanding more attention to their preferences, more participation in the system's operations, and more access to information necessary for informed choice.

Happily, the IOM, as Lohr's review of its activities amply demonstrates, has responded to these developments, cognizant of the currents and cross-currents they have set in motion. The Institute has explored the relation between quality and cost. It has defined quality to include patient preferences, while providing tools for measuring quality of life (the outcome of care) in ways meaningful to everyone, In assessing access to information, it has balanced nicely the need to know with the need to offer protection to both customer and provider. And it has advanced quality by holding it always as the most compelling goal, by setting standards that serve it, and by developing methods by which it may be assessed and, where needed, improved.

No doubt in obedience to her charge, much of Lohr's review deals with the strategies and methods of quality assessment and assurance. Here, perhaps the two most important developments the Institute has had to face have been the remarkable recent advances in informational technology and the infiltration



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