Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 17
~ ~ ~ ~ ~ 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
OCR for page 18
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 pnnciple—im-
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-
OCR for page 19
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
OCR for page 20
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
OCR for page 21
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
OCR for page 22
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.
OCR for page 23
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
OCR for page 24
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)
Representative terms from entire chapter:
care delivery
