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subjective well-being) should be consistently evaluated in determining the effectiveness of health care interventions.

  • Generic population and disease-specific health measures are relevant to the management of a population's health.

  • Plans need to evaluate systematically individual and population health risk behaviors in developing targeted interventions that could reduce avoidable health costs and increase the likelihood of positive health status over time.

  • Accreditation, licensing, quality auditing, performance monitoring, and other accountability mechanisms have limited impacts when they are instituted in a piecemeal or uncoordinated fashion. For example, external oversight processes may adequately monitor the overall quality of care, but oversight tends only to identify problems rather than to help solve them, especially when the solutions may involve changes in the internal procedures of an organization.

  • Quality of care requires cooperative commitments to quality-related goals by payers, practitioners, consumers, regulators, and managed care organizations, as well as a common and practical system for measuring and analyzing quality-related information.

Purchasers share with responsible managed care organizations and consumers a unifying goal of creating a more responsive health care delivery system, that is, one that is both more efficient and more effective. Over time it is probable that a best practices system will emerge that monitors, measures, and reports on the relevant information needed to determine effectiveness in sensitive, reliable, specific, and valid terms. The process of developing best practices will be facilitated if purchasers and managed care organizations include a variety of stakeholders in the discussions, including practitioners, administrators, researchers, accreditation organizations, public agencies, and the general public.

The quest for best practices and affordable systems is one of the current megatrends in health care, spawning a new industry that may provide the tools that stakeholders in the U.S. health care system need to make quality-based decisions. During the next few years of systems experimentation and consensus development, quality-related accountability will continue to develop in a variety of ways and will require leadership (Ellwood, 1988). It is now unclear by what means payers, providers, consumers, managed care organizations, and other stakeholders will come together to develop consensus about the systems that promote gains in personal health and the public good. Leadership will be needed to guide each step in this development and consensus-building process.

PERFORMANCE MEASUREMENT IN THE PUBLIC SECTOR

Performance measures are used to monitor progress made by agencies in reaching public health goals. Information from performance measures sometimes is used by agency administrators to justify the use of public funds. In addition, the



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