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~ ~ ~ ~ ~ Hi ~ The Changing Health Care Delivery System The purpose of the health care system must be to continuously reduce the impact and burden of illness, injury, arid disability, and to improve the health andfunctior~ing of the people of the United States. Advisory Commission on Consumer Protection and Quality, 1998 The U.S. health care system has experienced a remarkable trar~sfonnation over the past decade. Managed care plans now enroll more than 80 million Amencans. Ninety-one percent of employees with health insurance were enrolled in managed care plans in 1999, up from 27 percent In 1988. This shift to managed care has brought both opportunities arid problems that touch how physicians practice medicine arid how other health professionals such as nurses and den- ~ . . Today, more than four out of tests, provide their services. We are pre- eve' ,~ five workers are enrolled in sente4, for example, with opposes managed care plans for more filthy Integrating medicine and public heath, and for in~oduc~ng into the heath care system sophisticated techniques for collecting, han- dling, and assessing data that will prove valuable in quality assurance, cost containment, arid research. Yet while some progress is evident, most of these opportunities remain ~realized. On the other harts, Marty of the problems are highly visible. They include a destabiliza- tion of academic medicine, growing anger among consumers over denial of care arid other restrictions, renewed escalation in health care 1 7

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Informing the Future: Critical Issues in Health costs, and increasing concerns that cost-containment efforts are af- fecting quality of care. An moving toward a system that meets the challenge of efficiently arid effectively improving people's health, the nation must be guided by a single organizing pnncipleim- The systems by which health care is delivered ant! financed must be designed to ensure that care is safe, effective, efficient, equitable, and [ailorect to each individual's specific needs and circumstances. proving the quality ot health care. While keeping costs in mind is cer- tainly important, focusing foremost on reducing costs, which too often has been the case in the past, cannot arid will not suffice. The systems by which health care is delivered and financed must be designed to ensure that care is safe, effective, efficient, equita- ble, and tailored to each individual's specific needs and circumstances. QUALITY OF HEALTH CARE SERVICES The Institute of Medicine has a history of conducting studies to im- prove the quality of health care, as well as to identify the changes in education and training necessary to achieve that goal. 18 We launched our most ambitious effort in June 199S, with the creation of the Committee on Quality of Health Care in Amenca. The committee was charged to provide the nation with a roadmap for changes that could trans- form the health care system into one that is safe, efficient, and consumer-centered. Among its attributes, this new system will provide a better working environment for physicians and other health care professionals, and it will allow individuals to participate in and, to the degree pos- sible, help direct the care they receive. The committee's first report, To Err Is Human: Buildtirlg a Safer Health System (2000), argues that safety freedom from acci- dental injury dunng medical treatment is a cntical first step in improving quality of care. Each year, there are an estimated 9S,000 avoidable deaths among hospitalized patients. The report con-

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The Changing Health Care Delivery System Diseases of the Heart Cancer (malignant neoplasms) Cerebrovascular Disease Chronic Obstructive Pulmonary Disease 726,974 539,577 1 59,791 1 09,029 Accidents and Adverse Effects (motor vehicle accidents = 43,458; all others = 52,186) Pneumonia and Influenza Diabetes Suicide Kidney Disease Liver Disease SOURCES: 1. Centers for Disease Control and Prevention, 1997. 2. IOM, To Errls Human: Building a Safer Health System, 2000. 95,644 86,449 62,636 30,535 25,331 25,1 75 eludes, in particular, that errors can best be prevented by designing systems that make it harder for health care professionals and other health care workers to make mistakes and easier for them to do the right thing. Even well-trained, consci- entious people working in poorly de- . . . errors can best be preventecl signed and managed systems will by designing systems that make it sometimes commit serious errors. harder for health care profession- Medical errors will be reduced and pa- aIs and other health care workers tient safety increased by focusing on to make mistakes and easier for the design and management of good them to do the right thing. systems. The report details a compre- hensive strategy for designing safety into the health system at all lev- els, and it explains how patients themselves Carl influence the quality of care they receive. In early 2001, the TOM will release several related reports. Crossing the Quality Chasm: A New Health System for the 21st Cen- tu~y is the culminating report of the Committee on Quality of Health Care in America. It proposes a strategy and action plan for improving the organization, delivery, and financing of health care in order to ad- ~9

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Informing the Future: Critical Issues in Health dress serious shortcomings in the quality of care. Envisioning a Na- tiorlalF Quality Report examines what aspects of quality should be measured and tracked over time in order to determine whether the nation's health care delivery system is improving in its capacity to provide high-quaTity care. The report lays out a conceptual frame- work for mon~tonng quality and provides examples of the types of measures that might be included in a national quality tracking system. Over the years, a number of studies have suggested that "higher- volume settings" that is, hospitals, physicians, and other types of providers who handle larger numbers of patients typically produce better health outcomes than do smaller settings. The Committee on Quality of Health Care in America, in conjunction with the National Cancer Policy Board, explored this apparent link. The resulting re- port, Interpreting the Volume-Outcome Relationship in the Context of Health Care Quality (2000), presents evidence on the relationship between hospital arid physician vol- ume and achieving better quality of . .. . . . . ~ . . . volume alone is an imprecise indicator of quality: Some low- volume providers have excellent outcomes, while some high- volume providers have very poor outcomes. . , . . ~ . . care and patient outcomes in eight clinical areas, arid it assesses the po- tential policy implications of using volume as a quality indicator. For ex- ample, higher-volume providers may have greater experience arid more so- ph~st~cated Antes, and they may use better organized systems of care arid multidisciplinary team approaches. However, volume alone is an imprecise indicator of quality: Some low-volume providers have excellent outcomes, while some high-volume providers have very poor outcomes. Furthermore, the perfonnance gap appears to narrow with time as procedures become well established, which suggests that volume may be most pertinent when a new technology is beginning to diffuse into general practice. ~ 1997, the Veterans Health A~nin~stration implemented a new national fonnulary the official list of drugs, devices, and supplies that may be used in treating patients at all of the agency's facilities. The goal, in part, was to reduce costs. However, many veterans ex- pressed concern that the new fonnulary was overly restrictive md 20

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The Changing Health Care Delivery System thus compromised clinical care. Description and Analysis of the VA National Formulate (2000) concluded that it is not overly restrictive and does appear to be reducing costs without demonstrable adverse effects on quality of care. But the report stressed that there are mani- fold opportunities to improve the policies and procedures that com- pr~se the system for managing the VA National Formulary. QUALITY OF LONG-TERM CARE With the aging of the U.S. population, more people are facing ques- tions about long-term care, for themselves or family members. At the same time, the quality of Tong-term care has raised concerns among local, state, and national policymakers and the public, including the users of these services and their families. Improving the Quality of Long-Term Care (2000) concludes that strengthening quality meas- urement and accountability programs for venous long-term-care options including nursing homes, residential care facilities, and home-based serv- Consumers can play an important role in encouraging and assuring quality of care. Federal ant' state governments should! encourage Ices wall be cnt~cal to serving an and support programs that provide Increasingly diverse mixture of peo- . . . consumers with information on ple who have varying cI~n~cal and long-term care options, on the personal needs and preferences. The report recommends actions that fed- Compliance of ~nct~v'~ua' care eral and state governments, as well as providers with state stanC'ar~s on complaint resolution mechanisms, private providers, Carl take to ~m- prove the quality of long-tenn care and to meet the needs of an increas- and on other quality-related issues. ingly diverse clientele. Consumers can play an important role in en- courag~ng and assuring quality of care. Federal and state governments should encourage arid support programs that provide consumers with infonnation on long-tetm-care options, on the compliance of individ- ual care providers with state standards, on complaint resolution mechanisms, and on other quality-related issues. 21

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Informing the Future: Critical Issues in Health ~ 50 ~40 30 35 s 3 20, '] I IIA IIB 41 111 IV Stage of Disease at Time of Diagnosis ~ Uninsured O Privately Insured Distribution of women with breast cancer by d~s- ease stage at time of diagnosis. SOURCE: Ensur- ing Quality Cancer Care, 1999; page 52. QUALITY OF CANCER CARE Each year, more than ~ million Amencms, or 3 percent of the population, require treatment for cancer. Even as new methods for fighting cancer are emerging from the nation's laboratones, some al- ready proven therapies are not reaching all of the people who might benefit. Many cancer patients may be getting the wrong care, too little care, or too much care, in the form of unnecessary procedures. Lack of medical coverage, social arid economic status, patient beliefs, physician decision-making, and other factors can stand between the patient and the best possible care. Ensuring Quality Cancer Care (1999), prepared by the National Cancer Policy Board, examines how cancer care Tom early detection to measures for easing the end of life is delivered in various regions of the nation. The conclusion: for many Americans with cancer, there is a wide gulf between what might be considered the ideal treatment arid the reality of their experience with cancer care. The report defines quality care and recommends how to monitor, meas- ure, and extend such care to all people with cancer.

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The Changing Health Care Delivery System Breast cancer is the most common cancer, arid perhaps the most feared disease, among women in the United States. Almost 180,000 new cases are diagnosed annually, and about 44,000 women die from breast cancer each year. Until more is known about breast cancer pre- vention, the best hope for reducing its toll is early detection. X-ray mammography (imaging of breast tissues) and physical examination of the breast are now the mainstays for detection, but new technolo- gies are emerging. In addition to over- coming the high costs of these new Breast cancer is the most common technologies, their expanded use also cancer, and perhaps the most depends, in the case of devices, on ap- feared disease, among women in proval by the Food and Drug Admini- the United States. Almost 180~000 stration; on their being adopted by new cases are diagnosed annually, health plans and providers; on devel- and about 44,000 women die from aping systems to support payment for breast cancer each year. screening and follow-up; and on how readily private firms bring the technologies to market. Experience from current mammography and breast self-examination programs also shows that success will depend on providir~g outreach to women, enhancing education of women arid providers, and increasing con- venient access to facilities and services. The National Cancer Policy Board is currently assessing the potential of these new technologies, and its report, Mammography and Beyond[: Developing Technologies for the Early Detection of Breast Cancer, will be released in 2001. HEALTH INSURANCE As the shape of the nation's health care delivery system continues to shift, knowledge about health insurance status and the effects of hav- ing or not having insurance becomes increasingly critical. The TOM has studied selective aspects of this issue and continues to engage in related activities. Information on our examinations of children's health insurance status, on the effects of not having insurance, and on the increasingly worrisome state of the country's health care safety net can be found in the next section of this publication, in the section on Demographic Trends. 23

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Selected Recommendations Related to Demographic Changes . . . Health Care Safety Net: Federal and state policymakers should ex- plicitly address the full potential impact of any changes in Medicaid policies on the viability of safety net providers and the populations they serve. Federal programs and policies targeted to support the safety net and the populations it serves should be reviewed for effec- tiveness in meeting the needs of uninsured people. The nation's ca- pacity to monitor the changing structure and financial stability of the safety net must be improved. (Americans Health Care Safely Net: /n- [act but Endangered Children: All children should have health insurance. Public and pri- vate insurers should be encouraged to develop affordable products that address the specific needs of children, including children with chronic conditions and special health care needs. Nonfinancial bar- riers to care should also be reduced. (America's Children: Health /n- surance and access to Care) Minority Health: Research and research funding relevant to cancer among ethnic minority and medically underserved populations should be more adequately assessed and should be increased. (The Unequa/ Burden of Cancer: An Assessment of NIH Research and Programs for Ethnic Minorities and the Mec/ica//y Underserved) Nutrition and Elderly People: Nutrition therapy provided by regis- tered dieticians should be a reimbursable service under Medicare. Availability of nutrition services should be improved in home health care settings, and standards for nutrition services should be strengthened in fong-term-care facilities. (The Role of Nutrition in Maintaining Health in file Nations E/der/y: Eva/uefing Coverage of Nutrition Services for the Medicare Popu/afion)