The quality of healthcare that is delivered to patients now represents a major focus for the governments of most Western democracies. Glenn Hackbarth, as chair of the United States Government’s Medicare Payment Advisory Commission (MedPAC), succinctly described the reasons for this governmental focus as follows: “U.S. healthcare is too expensive and the quality is too inconsistent” [1]. However, this US Federal governmental focus on healthcare quality has existed since the Clinton Administration as reflected in the report of a Presidential Commission entitled Quality First [2]. Subsequent US Institute of Medicine reports entitled “To Err is Human” [3] and “Crossing the Quality Chasm” [4] further raised the issue of the quality of care delivered by the US healthcare system and led to an even greater focus on healthcare quality. It has been frequently observed that the United States expends 50–100 % more than other Western democracies on healthcare and has a lower life expectancy [5]. Recent data also show that governmental sources now account for at least 45 % of the total healthcare expenditures in the US [5]. Since Federal and state governments are providing such a significant fraction of the payments for healthcare and represent the people of the US who have an obvious interest in the quality of the healthcare that is provided, it is not surprising that this major payor has continued to make efforts to improve both the cost and quality of healthcare.

One of the first steps that the Federal Government undertook to attempt to improve healthcare quality began with the National Technology and Transfer Advancement Act 1995. As a result of this act and based on recommendations from the Presidential Commission on Consumer Protection and Quality in the Health Care Industry, the National Quality Forum (NQF) was established as a voluntary, consensus standards setting body for quality measures. A rigorous, evidence-based review of proposed quality measures through a formal consensus development process was established, and the NQF has now become the gold standard for healthcare performance measures. Importantly, governmental agencies were obligated under this Act to use NQF measures quality measures that were adopted through the NQF process rather than each developing their own measures. Funding for the NQF continues to come from grants provided by government and not for profit foundations, and from member dues and government contracts. Membership is currently over 300 healthcare institutions, health insurers, government agencies, and professional organizations. The current missions of the NQF include (1) Building consensus on national priorities and goals for performance improvement, (2) Endorsing national consensus standards for measuring and publicly reporting on performance, and (3) Promoting the attainment of national goals through education and outreach programs. The Society of Thoracic Surgeons was one of the first physician organizations to propose a set of quality measures for surgical coronary artery revascularization procedures which were adopted through this NQF process. Subsequently, the STS also proposed a series of measures for congenital heart surgery, and many of these were adopted as well.

The most important Federal action in the healthcare sector has clearly been the Affordable Care Act which became law in 2010. Several sections of this legislation were drafted in an attempt to achieve the dual goals of cost reduction and improvement of quality and patient access to healthcare, and these were summarized by Kocher and Sahni in 2010, who also noted that 10 % of patients account for 64 % of all US healthcare costs [6]. A key goal of this legislation was to achieve coordination of care among various providers of healthcare, and the legislation provided for the formation of “accountable care organizations” which would receive payments for the management of populations rather than individual patients but would also have to meet quality goals that would be established. These accountable care organizations would be allowed to share in the savings that occurred through the coordinated efforts of physicians, hospitals, and other providers in these accountable care organizations. These savings were anticipated to result from the development or redesign of care processes to achieve both high-quality and high efficiency. Kocher and Sahni also noted that a key question was whether physicians or hospitals would control the ACO’s, and noted that whoever controls the ACO’s will capture the largest share of any savings [6]. Initially, 65 quality measures in the 5 domains of patient experience, care coordination, patient safety, preventive health, and the health of “at risk” and frail elderly populations were adopted. In addition, the ACA also provided for funding of “medical homes”, which were to be community based, interdisciplinary, inter-professional teams that support primary care practices. An additional provision of the ACA directed at incentivizing more coordinated and less costly care were bundled payment programs for standard surgical procedures. These bundled payment programs were proposed as pilot programs for procedures such as coronary artery bypass surgery and hip replacement surgery. An additional provision was directed at reducing hospital readmissions by reducing the payments to hospitals for the care delivered to patients who were readmitted within 30 days of hospital discharge with the rationale that these reduced payments would motivate hospitals to engage with care coordinators to organize better delivery systems for post-hospital care. Reductions in payments were also mandated for “hospital acquired conditions” to provide hospitals an incentive to standardize protocols and procedures to reduce hospital-acquired conditions such as urinary tract infections and pneumonias. The impacts of the implementation of the ACA on healthcare quality and costs are still being acquired, but the results of the Physician Group Practice Demonstration, which began as a medical home demonstration project prior to the enactment of the ACA have been mixed [7]. Additional funding was provided to increase the use of electronic health records to further improve the coordination of care across providers and sites of care. An additional Executive Branch initiative, under the leadership of Dr. Donald Berwick during his tenure as acting administrator of the Centers for Medicare and Medicaid Services, was the formation of the “Partnership for Patients”, which aimed to save 60,000 lives by stopping preventable injuries and complications in patient care. This initiative gathered pledges of support from 4,500 organizations and included a $500 M demonstration project focused on Community-Based Care Transitions and the development of a CMS Innovation Center, which was designed as a mechanism by which hospital systems could spread best practices to reduce hospital-acquired infections. The outcomes of all of these provisions of the ACA directed at improving quality and reducing costs remain unknown.