The key elements of quality health care are continuity of care; affordability; health enhancement and well-being services; and access to effective, efficient, safe, timely, patient-centered care. ^[1]   Good program evaluation can drive improvement in performance through the measurement of access to care and the quality of clinical care. ^[2]   However, there are insufficient studies comparing treatment modalities and the performance of different providers. Both patients and government agencies which fund care would benefit from such comparative data. A system-wide effort to improve quality should increase investment in the generation and dissemination of information about effectiveness and cost-effectiveness to improve options available and patients' ability to make educated choices among those options. ^[3]   Policymakers should therefore encourage performance studies of health programs, including analyses of the performance of managed care programs funded through Medicaid.

In addition to promoting evaluation generally, policymakers should promote well-managed, comprehensive primary care by offering financial incentives to providers that can demonstrate improvements in their efficiency, comprehensiveness, and quality. ^[4]   Some performance-based tools which measure access to care and quality of care have already been established. The National Committee for Quality Assurance (NCQA) has developed one such tool. NCQA's Health Plan Employer Data and Information Set (HEDIS) is a set of standardized performance measures designed to evaluate performance of managed health care providers on a number of key care and service dimensions, including the value of selected treatment and prevention interventions for chronic and communicable diseases. The HEDIS performance measures are related to many significant public health issues such as cancer, heart disease, smoking, asthma, and diabetes. Providing such information to consumers, funders, and policymakers enables them to make educated decisions about their own health care and health care policy generally.

Further, policymakers should give financial incentives to government-subsidized primary care providers that demonstrate consistent improvement, including those funded through Medicaid. This would have the double effect of encouraging evaluation and encouraging high-quality care. Providers could be assessed for their HEDIS scores on access to care and quality of care. HEDIS is not the only standard for evaluation, however, and providers and researchers should be encouraged to develop other validated instruments.

Bonuses should also be granted to practitioners who demonstrate improved prevention strategies, such as immunization or screening for sexually transmitted disease. Improvements in care for conditions particularly prevalent among the poor, such as asthma, hypertension, diabetes, elevated lipids, viral hepatitis, and HIV/AIDS should also warrant recognition. Such measures would not only improve patients' health (and public health generally), but could produce efficiency and financial savings for states funding such care. ^[5]   In Rhode Island, a statewide managed care program which contracts with the state Medicaid agency has achieved significant gains in treatment outcomes by providing pay-for-performance incentives to community health centers and other high volume primary care practices. For example, between 1999 and 2003, adolescent immunization increased from 45 percent to 76 percent; the proportion of diabetics whose conditions were well controlled rose from 53 percent to 60 percent; and the proportion of diabetics who were appropriately screened for elevated lipids increased from 51 percent to 89 percent.

As detailed above, early interventions protect against morbidity and mortality, as well as providing cost-benefits. Closing quality gaps through concerted policy efforts, such as providing incentives and paying for high or improved performance, reduces the direct expense of medical care. For example, in the US each year, taxpayers stand to save $573 million by improved control of diabetes and $191 million through appropriate screening for colorectal cancer. ^[6]