SANDRA J. TANENBAUM
and Physician Accountability in the
Era of Medical Outcomes
Although health care reform remains unconsummated, there exists broad consensus—among congressional allies and enemies, interest groups of every stripe, and otherwise nonaligned members of the public—that the U.S. health care system is a wasteful one. Its substantial expenditures are patently misguided, yet it is unaccountable to payers and patients for how much is spent and on what. 1 In fact, a far-flung movement for "assessment and accountability" on the part of providers (and especially physicians, on whom this paper is focused) has been designated the "third revolution in medical care." 2 Virtually every recent proposal for reform posits informed consumers, choosing among competing providers, who in turn offer assessment of, and accountability for, the cost and quality of health services.
Oddly enough, the definition of "accountability" in this health care context is mostly unspecified. To be sure, the term always implies answering for— that is, bearing the consequences of—one's actions. In our market-based health care system, this usually means bearing the economic consequences of consumer dissatisfaction, and because health care is not an ordinary consumer good, "consumer" dissatisfaction may affect the patient himself, his payer, or the responsible regulatory agent. In any case, accountability for health care typically means the measurement of some aspect of care against a preconceived standard. Promotion of appropriate standards comprising medical outcomes has recently been most influential. It is sometimes referred to as the "outcomes movement." 3
Here I offer a critique of the outcomes movement and of the applied‐ science model of medical practice on which it rests. More to the point, however, this paper argues that the dominant definition of "accountability" is