The relationship between cost and quality is more than an academic concern. Assumptions about the strength and direction of the association are at the heart of the current debate about the future direction of American health care. If we assume that quality and costs are positively related, then it follows that efforts to contain costs threaten quality.1 If we assume a less linear or even negative relationship, then cost containment and quality improvement may even be complementary.2
See also p 1903.
Donabedian et al3 suggest that the use of health services beyond those needed for maximum health benefit might actually have a negative effect because of complications of the unnecessary tests and treatments. Empirical studies of the cost-quality relationship have been largely confined to hospital care and show no consistency in the direction of the associations.4 The article by Starfield et al5 in this issue