Health Affairs, 27, no. 3 (2008): 748 doi: 10.1377/hlthaff.27.3.748 © 2008 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Quality & Accountability

PROLOGUE

Improving Quality And Accountability

Reformers who concentrate too narrowly on insurance coverage—broadening availability, paying the tab, or both—tend to suffer a similar fate: for them, the health care system resembles a tollgate. But is a higher-efficiency toll plaza the answer, when the road beyond it cannot carry current, let alone increased, traffic?

Calls to repair and realign our health care delivery system are far from new. Yet, the contributors to this section tell us, they are more urgent than ever. Massive postelection coverage extensions, if realized, will ultimately fail unless the delivery system can be made to provide higher-quality, better-coordinated, and better-integrated care, at a supportable cost. If widespread reform fizzles after the 2008 ballots are counted, delivery system reform will still be needed to address the status quo: a system of which Americans are increasingly critical, because it costs far more, but may deliver less, than its counterparts in other developed nations. Moreover, this reform will need to occur on an unprecedented scale. Given the unusually large number of moving parts and stakeholders involved, whose autonomy (at least in this context) tends to be more of a bane than a blessing, it must be driven by a rare commodity: a broad, balanced, and integrated vision that all parties can embrace. The authors of the following papers offer their attempts to fill that tall, timely order.

Margaret O’Kane and fellow members of the Quality Crossroads Group present a five-pronged approach to building a high-performance health system. They rethink, reintegrate, and expand upon familiar concepts and strategies in key areas—such as performance measurement and accountability—to propose broader-based initiatives than previously attempted. At the same time, they envision novel structures (one of them brick-and-mortar) to facilitate and monitor success.

Donald Berwick and colleagues likewise advocate a multipronged approach to accomplishing multiple goals: the "triple aim" of improved individual care experience, improved population health, and reduced per capita costs. Recent experience, they encourage us, has demonstrated that these sometimes conflicting goals can be achieved simultaneously, as long as certain preconditions are met—including the existence of an "integrator" that ensures pursuit of all three goals, in the proper balance for the population served.

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