THE OVERSIGHT OF MEDICAL-CARE - A PROPOSAL FOR REFORM

The oversight of medical care, in the form of peer review, has traditi onally been used to ensure that the highest standards of care are main tained. What is relatively new is the external oversight of medical pr actice carried out by a growing number of independent entities (govern ment, third-party payers, for-profit firms, for example), overseeing c are in uncoordinated ways. Tensions arise when reviews of utilization and reviews of quality are conducted by different organizations with c onflicting goals. The review instruments are still crude and have neit her been adequately tested nor validated. Future attention to developi ng reliable and valid measures of efficiency and quality is essential. Evidence suggests that the principal process of review, the case-by-c ase review, may not be cost-effective and may not be conducive to impr oving quality. It should be replaced by profiles of practice patterns at institutional, regional, or national levels. We propose a model of oversight that emphasizes the appropriate balance between internal mec hanisms of quality improvement and external accountability. In this mo del, internal and external reviews have specific, complementary roles that promote efficiency and quality. Detailed monitoring of quality an d problem solving are left to providers who are intimately involved wi th care. In return, they become accountable to payers and the public t hrough the surveillance of patterns of practice.