At its most general, accountability is about individuals who are responsible for a set of activities and for explaining or answering for their actions. Accountability therefore entails procedures and processes by which one party provides a justification and is held responsible for its actions by another party that has an interest in the actions [4, 5]. Many questions about specifics remain. Who are the parties that should be held accountable? By whom? What are the issues for which these parties are held accountable? What are the standards for accountability? How and by what procedures should the parties be held accountable? To help elucidate the concept of accountability, we consider the components of accountability—the who, what, and how—by defining the parties in health care that can be held accountable, the issues for which a party can be held accountable, and the appropriate mechanisms for accountability in health care. We then delineate three models of accountability—the professional, the economic, and the political—elucidating the role of the patient and the physician, the manner in which health care is valued, procedures for expressing disagreement, and institutional structures established to implement accountability. Finally, we critically evaluate the models and consider the institutional arrangements necessary to realize a preferred model of accountability.

The Components of Accountability

Who—The Locus of Accountability

In health care, at least 11 distinct parties can be held accountable or hold others accountable: individual patients; individual physicians; nonphysician health care providers such as nurses and physical therapists; hospitals; managed care plans; professional associations; employers, such as General Motors; private payers, such as Blue Cross; the government; investors and lenders of capital; and lawyers and courts. This list is neither exhaustive nor immutable. There may be other parties, such as pharmaceutical companies; as health care evolves, other parties may develop important roles in health care, and some of the listed parties may play less important roles. In addition, some of the parties play multiple roles. For example, through the Health Care Financing Administration, the government acts as a payer; through Veterans Affairs Hospitals, it acts as a health care institution; and through Congress and other elected bodies, it can act as a community advocate and representative.

What—The Domains of Accountability

A domain of accountability is an activity, practice, or issue for which a party can legitimately be held responsible and called on to justify or change its action. Accountability in health care consists of at least six domains: professional competence, legal and ethical conduct, financial performance, adequacy of access, public health promotion, and community benefit.

Some domains of accountability such as competence and legal and ethical conduct are well accepted; others are more contested. For instance, most agree that "the financial matters for which [providers are] (or could be) held accountable include the price of services, the efficiency with which they are provided, assurance that services billed for were delivered, and the overall financial performance and economic health of the [providers]" [5]. However, adequacy of access has been even more controversial. Medical associations and prominent physicians have argued for a physician's "duty to care for the poor," but efforts have not been systematically supported and have never been required for licensure or certification [6-8]. Similarly, public health promotion, although often supported by physicians and medical associations, has never been a component of physician licensure or certification [9-11]. Some also doubt whether community benefit is part of accountability in health care. Yet, some physicians and health care organizations have viewed their mission to be as much community development as reduction in morbidity and mortality, and others have tried to define a "community benefit standard" by which to assess hospital performance [12-16]. Thus, we include even the contested areas in the nosology of domains for accountability.

Operationally, within any domain, a party will be held accountable for specific content areas based on substantive criteria, which some commentators call managerial accountability [4]. For example, within the area of competence, a physician might be held accountable for risk-adjusted mortality rates for a particular disease, complication rates for certain procedures, screening test rates, or overall patient satisfaction. For each content area, criteria are established for evaluating performance. The criteria can be either explicit or implicit. Existing explicit criteria for professional competence have included hospital mortality rates collected and published by the Health Care Financing Administration and malpractice claims filed in the National Practitioner Data Bank. Similarly, explicit criteria for the financial performance of physicians in some managed care plans have included the number of specialist referrals and test-ordering patterns. In the realm of legal and ethical conduct, nonbinding resolutions by professional organizations can be substantive criteria. Implicit criteria for professional competence might include perceived quality based on press reports. Over time, implicit criteria can evolve into explicit criteria [4, 5].

How—The Procedures of Accountability

In general, there are two components to the procedures of accountability. The first is evaluation of the adherence to or compliance with the criteria for specific content areas. The second is dissemination of the evaluation and responses or justifications by the accountable party or parties. Different procedures for evaluation and dissemination are appropriate to the different domains. In addition, the procedures for evaluation and dissemination can be formal or informal. Formal procedures of evaluation may include inspection of facilities, records, and policies by the Joint Commission for the Accreditation of Healthcare Organization and review of surgery-related mortality and morbidity data of hospitals and surgeons. The latter has been done for cardiac surgery in New York State. Importantly, many of the mechanisms for evaluation are underdeveloped and need substantial innovation, research, and refinement. In the domain of professional competence, for example, it is often desirable to assess risk-adjusted mortality and morbidity for physicians, hospitals, managed care plans, and others. However, the technical capacity for risk adjustment and other assessment standards, necessary formal accountability procedures, is still lacking. Similarly, formal procedures are available for disseminating evaluations and responses, including public hearings, certification and licensure, and, with increasing prominence, "report cards." Informal procedures for evaluation and dissemination include comments during consultations between physicians for professional competence, selections of providers in the marketplace for financial performance, and evaluations by the press, such as the ranking of hospitals by U.S. News and World Report. Bradford Gray [5] has stated that

the matters for which an institution is accountable to patients differ from those for which it is accountable to payers, or physicians, or providers of capital, or regulatory agencies. Moreover, the mechanisms of accountability vary substantially in their formality, ranging from the detailed contractual arrangements that are part of the capital acquisition process (for example the issuance of bonds, or the minutiae of the accreditation process) to the informal influences on hospitals of physicians and patients via the accountability of the marketplace.

The selection of content areas, substantive criteria, and the procedures for evaluation and dissemination can be controversial both on the basis of the technical ability to accurately evaluate performance and on the basis of values, which are often framed in terms of appropriateness [4]. Much of the current debate on evaluation, such as that on defining quality criteria or the components of a report card, can be viewed as a contest over the proper content areas, criteria of accountability, and ability to assess the fulfillment of the criteria. In the accompanying article in this issue [17], the Working Group on Accountability characterizes within the domain of ethical conduct the substantive content areas and evaluation and dissemination procedures for which physicians and health care institutions should be held accountable.

An autonomous or self-regulating profession is one that determines which domains are primary, specifies the specific content areas and substantive criteria in each domain, and controls the procedures of accountability, especially the formal processes.

The Matrix of Accountability

The different parties that interact on matters of accountability over many different domains and mechanisms create what we might call a complex reciprocating matrix of accountability (Figure 1). A given party can be accountable to 10 other parties—and each party can potentially hold another party accountable in 1 to 6 domains. For example, physicians can be accountable to the government in all domains. In addition, physicians can be accountable to private payers, such as insurance companies, for professional competence and financial performance; to hospitals for professional competence, legal and ethical conduct, and financial performance; to professional associations for professional competence, legal and ethical conduct, and, informally, adequacy of access and possibly public health promotion. Reciprocally, physicians, patients, and others can hold some of these parties accountable. The physician might hold professional associations accountable for standards on professional competence and legal and ethical conduct; hospitals accountable for professional competence, legal and ethical conduct, financial performance, and adequacy of access and community development; and payers accountable for financial performance and, informally, adequacy of access. The result of this reciprocal accountability for each party over many domains is a multilateral, often reciprocating, matrix of accountability.

View larger version (26K): [in this window] [in a new window]   Figure 1. Accountability of the physician.

Models of Accountability

Different models of accountability stress different domains, evaluative criteria, loci, and procedures as being primary. We delineate three dominant models of accountability (Table 1). These models are descriptive, Weberian ideal types [18] and therefore do not characterize the actual process of accountability in existing health care organizations; in practice, components of accountability from the different models are often used simultaneously within a single organization. Rather, these models clarify our thinking by illuminating different analytic conceptions of the essential characteristics of accountability. These models are also normative ideals that can guide health care reform and the design of institutional structures for accountability [19]. Because physicians still constitute the most powerful group of health care providers and because more attention has been given to physician accountability than to accountability of nonphysician providers, we focus on physicians.

The Professional Model

In medicine, the traditional model of accountability has been the professional model [20-22]. The physician's actions are directed toward the patient's health or well-being, which is defined through discussion and deliberation with the patient. Patients, therefore, are participant-recipients; they are simultaneously participants in collaborative decision making and recipients of physician recommendations, services, and care. In this model, health care is not a commodity but a professional service. The physician's financial remuneration is secondary to the patient's well-being; procedures are implemented—not always successfully—to ensure that financial considerations do not conflict with or undermine the physician's pursuit of the patient's best interests [23-26].

The professional model consists of two primary loci of accountability: physicians to their professional colleagues and organizations and to their individual patients. Traditionally, accountability has focused on competence and legal and ethical conduct. Professional associations, such as state licensure boards and the Joint Commission for the Accreditation of Healthcare Organizations, establish the content areas and the substantive evaluative criteria and propagate them through education, licensure and certification, and discipline of those who deviate. Because professional associations infrequently monitor individual physicians, this formal and explicit accountability is supplemented by an informal but ubiquitous mechanism of accountability to individual colleagues. Through consultations, routine review of cases at conferences, annual review of hospital privileges, and other circumstances, individual colleagues invoke, affirm, and enforce professional standards of practice and conduct. By defining and enforcing these standards of competence and ethical conduct, the profession is said to be autonomous; physicians are simultaneously the regulators and the regulated and therefore are infrequently subject to external standards or enforcement by laypersons, government, or nonprofessional bodies:

[T]he ideal of a profession calls for the sovereignty of its members' independent authoritative judgment. A professional who yields too much to the demands of clients violates an essential article of the professional code: Quacks, as Everett Hughes once defined them, are practitioners who continue to please their customers but not their colleagues. [This focus on] colleagues in the orientation of work [is what] professionalism demands [27].

Over the last few decades, physician accountability to individual patients has become more prominent. This responsibility is mediated by the standards of the profession. The prototypical but not exclusive mechanism by which patients express their dissatisfaction with their physician or hospital is malpractice litigation, in which the patient claims that the physician did not adhere to the profession's self-defined standards.

The Economic Model

A second model of accountability is the economic or consumerist model, in which the accountability of the marketplace is applied to health care. In this model, individual patients are viewed as consumers; physicians and hospitals, as providers or economic producers; and health care, as a commodity or product. As in their choice of other commodities, consumers should compare the performance of various providers on price and quality and choose the provider who best satisfies their subjective desires. Just as manufacturers compete for a greater market share, providers endeavor to offer the best product at the lowest price. A successful provider attracts the most consumers.

In the economic model, the fundamental locus of accountability is the relationship between individual consumers and providers of health care—physicians, hospitals, and managed care plans. However, to ensure efficient, competitive, and fair operation of the market, there is a role for a marketplace regulator. Traditionally, this role has been entrusted to the government, the only body with sufficient power and resources to oversee providers. The primary domains are price and quality—financial performance and professional competence. Accountability is mediated by the marketplace, where the mechanism for expressing dissatisfaction is what Hirschman [28] calls "exit." Consumers are supposed to switch away from ("exit") poor providers, whose "revenues drop, membership declines and management is impelled to search for ways and means to correct whatever faults have led to [consumer] exit" [28].

For the market to work, consumers must be able to easily switch among providers and must have accurate and accessible information on the price and quality of providers [29]. In general, such information has been lacking. Consequently, many individuals and groups, such as the National Committee for Quality Assessment, are trying to develop objective measures of quality, which are to be combined with standardized prices in a "report card" that consumers can use to choose among providers [30]. Although professional associations can participate in defining and applying these objective quality measures, the economic model does not necessitate their participation. Just as Consumer Reports can evaluate telephone quality independently of manufacturers, so too can nonphysicians establish quality measures and evaluate provider quality in health care. Indeed, to obviate conflicts of interest and ensure independent, objective assessments, some argue that individual providers and professional associations should be excluded from establishing these measures.

The Political Model

A third model of accountability adapts the mechanisms of accountability found in the political sphere to health care. In this model, patients and physicians interact within a community. Individuals are neither trusting patients nor price-conscious consumers but are more akin to citizen-members [31]. Similarly, physicians are not merely economic producers and are more than health professionals; they too are citizen-members. From the citizen-members come governing representatives to operate the health care community. For instance, patients and physicians might serve on a managed care plan's board of trustees. In the political model, patient well-being is neither a commodity nor a professional service defined by individual physicians and patients. The goal of health care remains the patient's well-being, but its precise content and the optimal mechanism for achieving it are subject to interpretation by the community of citizen-members.

In the political model, the fundamental locus of accountability is the relation of providers to a governing board of representatives. In turn, this board is accountable to the members, both patients and physicians. The main procedure of accountability is "voice" [28]. Through some forms of consent, such as periodic election or explicit endorsement of management policies and decisions, individuals seek to influence or reform their physician's or health care community's behavior. "The [health plan's] customers or the organization's members express their dissatisfaction directly to management or through general protest addressed to anyone who cares to listen" [28]. Procedures for this might include using a patient board of directors to oversee the health care institution or having physician-patient or community-owned cooperatives. "Voice," however, is not the only mechanism for expressing dissatisfaction in the political model. Any citizen can exercise the "exit" or malpractice options.

In the political model, the primary domains of accountability are not fixed; after listening to both health care providers and patient-members, the board offers an interpretation of patient well-being that defines the domains and substantive content areas for accountability. Once the members approve the domains and substantive content areas, they form the basis for defining the criteria by which the board holds the providers accountable. Consequently, in the political model, a "report card" does not capture essential elements of health unless the specific communities explicitly endorse or adopt the specific standards for evaluation.

In the political model of accountability, the relevant community need not be a formal governmental unit; rather, political accountability refers to the decision-making process within an organization. Although political accountability has never been dominant in the U.S. health care system, it has played a role. For example, some managed care plans, such as Group Health or Puget Sound, are patient cooperatives and have patient boards of trustees; many neighborhood health centers are "community controlled" [32, 33]. Despite its flaws, Oregon's process of public hearings for Medicaid was an important exploration of political accountability in the allocation of resources [34]. Similarly, in Canada, "numerous provincial government reports have advocated increased citizen participation in health [decision-making, especially related] to the numerous value considerations central to today's health care resource allocation decisions" [35]. In Germany, representatives of employees and employers control the sickness funds and determine the level of premiums paid to the fund [36-38].

In some sense, all accountability in health care falls within a larger framework of political accountability. Ultimately, the state decides whether the medical profession will have more or less self-regulatory authority, whether market forces will be encouraged or discouraged in health care, and whether organized patient representatives will be given a larger or smaller voice in the administrative decision making of health care institutions. As Freidson [21] put it:

The foundation of medicine's control over its work is thus clearly political in character, involving the aid of the state in establishing and maintaining the profession's preeminence ... . The most strategic and treasured characteristic of the profession—its autonomy—is therefore owed to its relationship to the sovereign state from which it is not ultimately autonomous.

Comparisons and Conflicts among the Models of Accountability

Although there may be other models of accountability (such as a regulatory model), these three models are dominant. The loci, domains, and procedures of accountability for these models are shown in Table 1.

These models cannot be readily integrated in actual practice; without careful construction, they may actually undermine each other [28]. Examples of conflicts are not hard to find. Many commentators have noted how the economic model conflicts with the professional model; as one prominent economist stated, the conflict is usually "medicine versus economics" [39]. The professional model relies on trust, collaboration, and shared interests between the physician and patient; the physician should be motivated to improve the patient's well-being. This is incompatible with the focus of the economic model on maximizing financial success as the provider's primary motivating force and on the hope that market forces—the need to retain and attract consumers—will ensure high quality. In addition, using the marketplace, with its ease of switching on the basis of price, conflicts with the continuity of care that is integral to the professional model [40, 41].

Similarly, switching providers conflicts with the importance of continuity and voice essential to the political model. Working within a health organization to express dissatisfaction and implement change requires time and commitment on the part of the patient, as well as the existence of institutional mechanisms for reporting complaints. Using mechanisms to encourage switching, such as tax limits on the deductibility of health insurance premiums and frequent open enrollment periods, makes the political model less viable. Moreover, the presence of economic accountability makes health care organizations resist embracing procedures necessary for political accountability. As Hirschman [28] states:

[W]hile exit requires nothing but a clearcut either-or decision, voice is essentially an art constantly evolving in new directions. ... The presence of the exit alternative can therefore tend to atrophy development of the art of voice. ... As a matter of positive political science, it is useful to note that the greater the opportunities for exit, the easier it appears to be for organizations to resist, evade, and postpone the introduction of internal democracy even though they function in a democratic environment.

None of this is to say that these models are inherently incompatible, only that it is a "rare bird [in which] both exit and voice hold important roles" [28]. Just because we want a health care system with collaboration, exit, and voice simultaneously does not mean these elements will coexist easily. To combine them synergistically requires careful institutional design.

A Historical Perspective on Accountability in Health Care

In the United States during the 19th century, medical care and medicine were part of the marketplace. No uniform standards were available for education, medical schools were commercial institutions, there were battling sects, and physicians were generally held in low social esteem [24, 27, 42, 43]. Partially as a result of scientific and technical advances and partially as a result of social changes, including respect for expertise engendered by Progressivism, medicine began to "consolidate its authority" during the end of the 19th century [27]. During medicine's "Golden Age," roughly the 1920s to the 1970s, a paternalistic version of the professional model of accountability, emphasizing accountability to professional organizations, dominated:

[Medicine] was at a historically unprecedented peak of prestige, prosperity, and political and cultural influence—perhaps as autonomous as it is possible for a profession to be. ... Its formal organizational representative—or professional association—has been delegated many of the powers that the state elsewhere has reserved for itself, and its practitioners have otherwise been quite free of lay interference [21].

Over the last few decades two trends have emerged. One has been to refine the professional model to incorporate more patient participation in defining health and well-being and in decision making [44]. This has occurred through, for example, the emphasis on shared decision making, elaboration of patient-centered criteria for informed consent, and incorporation of patient-centered quality-of-life and satisfaction measures in evaluating medical interventions [45]. Simultaneously, however, the economic model of accountability has also become increasingly prominent if not quite dominant [46, 47]. This is probably most clearly manifest in managed competition, toward which health care is rapidly evolving even without health care reform legislation [2, 3, 48-53]. In managed competition, patients are supposed to be "cost conscious buyers shop[ping] for the lowest price," whereas physicians, hospitals, and others are "the provider community ... divided into competing economic units" [52]. The willingness of consumers, whether they are individual patients or employers, to leave one managed care plan for a cheaper, higher-quality alternative is the essence of accountability. Consistent with the economic model, Enthoven and Kronick [52] describes "the market in a system of managed competition ... as ‘three-cornered’—including consumers, health plans [that is, providers], and sponsors—and not merely two sided."

The Ideal Model of Accountability in Health Care

With the dramatic changes in health care, especially the explosive growth in managed care and the shift of patient care from individual physician offices to large organizations, it is necessary to explicitly consider the following question: What model of accountability should exist in health care? We cannot simply return to medicine's "Golden Age," when the professional model reigned. In large measure, this is because medicine has become too complex. In the late 19th and early 20th centuries, fewer diagnostic and treatment choices were available, and the social structure was correspondingly simpler, with only three parties to health care—the patient, the physician, and the medical associations. Today, health care is increasingly complex, with myriad diagnostic and treatment approaches requiring extensive specialization, collaboration, and integration into complex organizational structures. In fact, medicine has become so extensive and labor intensive that it supports one of the healthiest industries in the United States.

Equally, however, most Americans do not want the economic model to guide their interactions with their physician or hospital. Americans want their decisions about their health care to be informed by their health care needs. This pervasive attitude animates the public's outrage over physician financial conflicts of interest, the capital amassed by nonprofit hospitals and for-profit managed care organizations, the high salaries of the chief executive officers of health care institutions, and other activities that portray health care providers as indistinguishable from business school graduates [53-58]. An antipathy to the economic model in health care can also be seen in the public's willingness to use political processes to force coverage by insurers and managed care plans of specific health services, such as longer hospital stays for normal vaginal delivery. This suggests that Americans value health care primarily as a nonmarket good and that the economic model of accountability is inappropriate, at least for parties directly involved in patient care [19].

In our current social and political context, we think the ideal model of accountability is a stratified model in which different types of accountability govern different interactions. We propose that professional accountability within physician-patient relationships be nested within political accountability at the level of managed care organizations. In turn, this political accountability is nested within various relationships in which the economic and political models may operate (Figure 2).

View larger version (18K): [in this window] [in a new window]   Figure 2. Stratified model of accountability.

The model that should guide core patient–physician interactions should be the professional model; physicians in their capacity as caregivers should be concerned chiefly with their individual patient's well-being and should be held accountable primarily for professional competence and adherence to legal and ethical standards of conduct. Individual patient care decisions within this relationship should be insulated from the personal financial interest of the physician [23-26, 41]. Of course, this does not mean that no decisions can be made on the allocation of resources and the provision of certain services to patients; it means that policies on allocating services should be made at an organizational level rather than by individual physicians whose financial interests are tied to such decisions [23, 31].

More controversial is the issue of what model of accountability should govern managed care plans. The physician-patient relationship is occurring more frequently within managed care plans or other integrated delivery networks, for which our institutions and judgments about accountability are less settled. For three reasons, we believe the political model of accountability should operate within managed care plans and other organized providers of patient care [31]. First, many of the decisions within managed care plans involve the allocation of essential health care resources, such as what services will be provided to patients as basic benefits and what services will be left to patients' discretion. Allocation decisions on health care entail fundamental considerations of justice and are therefore value-laden moral and political decisions [31, 59-62]. Traditionally, Americans have not left such moral decisions to the market. Justice demands that individuals affected by such moral decisions must—at least in ideal circumstances—have a shared voice in making them [59-63]. The political model of accountability provides mechanisms for members of managed care plans to participate in the allocation decisions that are unavailable in the other models of accountability. This does not mean that these managed care plans should be government bodies, only that their decision-making processes should incorporate participatory elements.

Second, specifying the goals of health care and the optimal means to achieve them—that is, deciding which domains and mechanisms of accountability are primary—also entails moral decisions that should reflect the values of those who receive the health care. Choices by the community about which domains should be primary (for example, preventive services compared with competent disease treatment) are possible only within the political model.

Third, there are significant differences in power among individual patients, physicians, and managed care organizations. In the economic model, patients act as individuals in deciding which provider to use or when to "exit." They are trying to affect a large organization with significant resources, yet their power as individual consumers is small. Also, in a marketplace, the mechanisms of accountability are implicit; it is never explicitly stated to the provider what factors motivate the individual's decision to either "exit" or remain with the provider [28]. This reduces the effective influence of individual consumers over critical decisions about health care. In addition, providers specify the choices of health care arrangements; consumers are not given a full array of options to choose from but only the limited range of service packages that providers believe will command sufficient market share to make them profitable. Conversely, in the political model, decision making is a collective action that leans toward equalization of power among patients, physicians, and administrators and gives individuals more influence in shaping the options provided them.

Implementing political accountability at the level of managed care plans has profound implications for the structure of these institutions. Plans that continue to place most decision-making power in the hands of administrators and physician employees would have to create governing structures that empower the patients. Such structures might include public forums for patients to both be informed about major policy and to provide "feedback" to administrators about their views. In addition, managed care plans could involve representative patient members in essential administrative and policy committees, such as those that review clinical guidelines, hospital contracts, or staff compensation. Finally, several studies suggest that requiring that the patients collectively own the managed care plans or having the managed care plan's board of directors be composed exclusively of patient members is the most effective mechanism for political accountability [33, 35]. Such a policy, in turn, may entail other changes, such as adopting multiyear rather than annual enrollment periods [31].

Creating political accountability in health care institutions has its own serious problems that cannot be ignored, including inefficiency, professional dominance, and decision-making paralysis [64]. Patients lack technical expertise for many of the key decisions confronting managed care plans. Thus, informing them about critical issues, having forums for discussions, and conducting votes are inefficient decision-making processes. Such processes may actually consolidate the power of experts—physicians and administrators—over decision-making and add the patina of community consent [32, 64]. Also, because patients are often too busy to attend meetings at managed care plans, interest groups must often be used instead. Frequently, persons with extreme positions dominate democratic decision-making processes, which makes such groups unrepresentative [35, 64]. In addition, because many decisions confronting a managed care plan involve value choices, a significant conflict among members in a pluralistic society could paralyze decision making [64]. Such problems are serious but can be mitigated if not completely overcome by using a patient board of trustees and similar institutional structures [12, 14, 33, 35].

Serious problems, however, are not the monopoly of the political model of accountability. The professional and economic models have their own problems. Any evaluation of these models must compare the problems of all alternative models and recognize that determining which set of problems is more acceptable is not only a technical but also a value judgment. In this comparison, it is important to acknowledge that efficiency is not the only value to be realized.

The strata beyond the managed care plan involves interactions between the managed care plan and government, employers, investors, and other health care institutions. In many of these "external" relations, it seems acceptable for managed care plans to use the economic model of accountability because the relations are not directly tied to clinical care decisions about individual patients. For instance, in the interaction with employers or investors, the main domains of accountability may be financial performance and professional competence, with "exit" being the mechanism for dissatisfaction. Yet, in interactions with the government and other parties, such as professional associations, the political model of accountability may be appropriate. It is important, however, that economic accountability present in "external" relations not undermine the models of accountability in the more central, "internal" health care relationships between physicians and patients and in the operation of the managed care plans. Ensuring this insulation of the various strata also requires careful institutional design, a topic we cannot address here.

Conclusion: Keeping the Models of Accountability Distinct

Two mistakes in accountability could have devastating implications for health care. The first mistake would be to simply apply one model of accountability to all of health care. Health care is currently too complicated, with too many parties consisting of diverse relationships, to be encompassed in only one model. We must resist the tremendous tendency within U.S. society to believe that the ideal solution for every complex social problem is the market and economic accountability [5, 19, 28]. Some of the essential aspects of health care—trust, collaboration, compassion, continuity—would be irreversibly lost by adopting economic accountability throughout the health care system [41].

A second mistake would be to confuse the different models of accountability that operate in different facets of the health care system. For most Americans, the expectation and hope is that personal health care relationships are, and should be, guided by the professional model. Trust among patients depends on being able to assume that physicians hold their personal patients' well-being primary and all other concerns secondary. In this era of rapid change, however, it is both tempting and easy for health care organizations to encourage this belief while actually adopting the economic model of accountability in their operations [25]. Such a ruse—portraying physicians as caring professionals while forcing them to act like economic producers—will ultimately discredit the entire practice of medicine and sow distrust and cynicism that cannot easily be overcome.

We have proposed clarification of the components of accountability by thinking in terms of domains, loci, and reciprocating matrices in which activities are accountable. More importantly, we have proposed a potentially clarifying conception of different models—professional, political and economic—of accountability. Finally, we endorse a stratified model in which the professional model should guide the patient–physician interaction, the political model should guide managed care organizational structure, and the economic model has a role in interactions among organizations. This stratified model of accountability is an ideal version of accountability for health care that should guide our reform efforts.

Dr. L. Emanuel: Division of Medical Ethics, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115.