PROLOGUE:In 1991 Avedis Donabedian wrote that "a health care system reflects the values adopted by a society and the ways in which it has chosen to conduct its affairs." Changes in the U.S. health care system in this decade have been testimony to these words, with government efforts giving way to the marketplace as the chief driver of reform. Now, with health plans at center stage, policymakers are turning their attention to the concern underlying Donabedian's statement-society's commitment to high-quality health care. In the managed care environment, the challenge of measuring and ensuring quality has taken on new significance, as health plans compete for market share and consumers and purchasers adjust to their new role in scrutinizing plan performance.In this essay, Alain Enthoven and Carol Vorhaus respond to the question: What would a high-quality health care delivery system look like? They identify practices and institutions that integrate or exemplify quality assessment and improvement, and they look at features of the managed care system that help create a quality-oriented health care infrastructure.Alain Enthoven is Marriner S. Eccles Professor of Public and Private Management in the Graduate School of Business at Stanford University. Carol Vorhaus is a research associate there. Enthoven has been a long-time participant in the Jackson Hole Group, a group of private-and public-sector figures that promoted managed competition as the most appropriate prescription for reforming the U.S. health care system. He also has influenced the direction of health care reform in several other countries (England and the Netherlands) that have embraced elements of the marketplace model.

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