Medical care value purchasing: medicolegal promises, pitfalls, and progress.

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Medical care value purchasing is the latest effort to promote cost containment while maintaining or enhancing the quality of medical care. The fuel driv ing this process is mandated health care cost and quality data disclosure to stimulate competition in oversupplied markets so that the highest quality and lowest cost providers achieve the greatest market share gains. States such as Pennsylvania, pursuant to Act 89, are in the vanguard of this national move ment, sometimes referred to as the "Buy Right Strat egy for Health Care Purchasing." The measurement of provider quality and cost-ef fectiveness will become a "growth industry" in the 1990s. Medical paternalism will give way to con sumer activism in health care decision making. How ever, there are certain medicolegal pitfalls arising from the promises associated with mandated data disclosure concerning provider cost and quality effec tiveness. One pitfall is that the unmeasurable quality attri butes (such as compassion and empathy) will fall into even greater disuse. Another pitfall may concern the further inflation of expectations of certain health care outcomes among consumers attending providers with the highest cost/quality ratings. Also, those pro viders losing patients will lose practical skills and any restraint they might have had from overutiliza tion on those few remaining fee-for-service patients left to them. All of these scenarios could result in increased litigation. Despite these potential pitfalls, medical care value purchasing represents a real advance in promoting quality and cost-effectiveness. Regardless of the un derlying motivation, these two worthy goals should be sought with increasing vigor in the days ahead. The ultimate benefit may well be the rising to prom inence of the "laser-beam" (as opposed to the "shot gun") approach to clinical diagnosis in our academic medical centers and other health care institutions nationwide.