1
Introduction

The provision of health care services to the diverse U.S. population represents one of the largest segments of the nation’s economy—approximately one-seventh of its gross domestic product (Centers for Medicare and Medicaid Services, 2002). The government health care programs that are the focus of this report—Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), the Department of Defense TRICARE and TRICARE for Life programs (referred to collectively as DOD TRICARE), the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program—account for over 40 percent of all health care expenditures in the United States. Consequently, the federal government has a central and pervasive role in shaping nearly all aspects of the health care sector, both public and private. A critical question is how the federal government can use this leverage to improve the quality of care for all Americans.

Quality of care can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990).



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Leadership by Example: Coordinating Government Roles in Improving Health Care Quality 1 Introduction The provision of health care services to the diverse U.S. population represents one of the largest segments of the nation’s economy—approximately one-seventh of its gross domestic product (Centers for Medicare and Medicaid Services, 2002). The government health care programs that are the focus of this report—Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), the Department of Defense TRICARE and TRICARE for Life programs (referred to collectively as DOD TRICARE), the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program—account for over 40 percent of all health care expenditures in the United States. Consequently, the federal government has a central and pervasive role in shaping nearly all aspects of the health care sector, both public and private. A critical question is how the federal government can use this leverage to improve the quality of care for all Americans. Quality of care can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 1990).

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Leadership by Example: Coordinating Government Roles in Improving Health Care Quality STUDY PROCESS AND SCOPE In 1999, Congress asked the Institute of Medicine (IOM) to convene a panel of experts to explore ways of enhancing the quality of care offered through government health care programs (the Healthcare Research and Quality Act of 1999, Public Law 106-129). Underlying the scope and intent of this study is the judgment that, by virtue of its breadth of involvement in health care regulation, purchasing, provision of services, and sponsorship of research and education, the federal government can and should have a significant influence on quality of care in all aspects of health care programs and services available to the American people, whether provided through a government health care program or not. To carry out this study, the IOM established the Committee on Enhancing Federal Healthcare Quality Programs. The committee’s mandate was to examine for each of the above six government programs those specific operational components whose function is to assure and improve the quality of care received by beneficiaries. The committee has chosen the term “quality enhancement processes” to represent the set of government activities encompassed by this function. Quality enhancement processes include, among other things, the following four components: Requirements directed at enhancing provider competencies, both for institutional providers and for members of the health professions Periodic or ongoing assessment of the quality of care, including measurement of the processes and outcomes of care Synthesis, analysis, and public reporting of quality assessment results by site or level of care Actions, based on the results of quality assessment activities, to effect changes in care processes or outcomes for defined categories of beneficiaries Beyond these four components of quality enhancement processes, other aspects of care delivery systems have a substantial impact on the safety and quality of care provided to any beneficiary population. For example, the committee recognizes (and in Chapter 2 comments on) the impact of basic health care benefits, payment approaches, and program design and administrative issues on the processes and outcomes of care. Technological and scientific advances and education in the health professions are other important factors, but outside the scope of this report. It is important to emphasize that the term “quality enhancement processes” implies much more than regulatory activities of governmental agencies. The federal government performs multiple roles in health care, including those of regulator; large group purchaser; health care provider;

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Leadership by Example: Coordinating Government Roles in Improving Health Care Quality and sponsor of health-related research, education, and training programs. The focus of this study is on quality enhancement activities of many kinds and at different levels intended to promote and enhance care processes and beneficiary outcomes. In addition, patient-centered (or consumer-centered) care has been identified as an essential element of quality health care (Institute of Medicine, 2001). An investment in quality enhancement within the six major government health care programs will, in itself, make a difference in the lives of about 100 million Americans served by these programs. In carrying out its fiduciary responsibility, the federal government has the opportunity to serve as an important beacon of influence within the larger public and private health care sectors. For most health care providers, institutional and individual alike, the government health care programs constitute an important source of revenue. Quality improvement activities undertaken within these programs are likely to have an effect on overall quality of care that reaches beyond the programs themselves. Conversely, and perhaps more important, without the federal government’s leadership, it will be difficult if not impossible to bring about the needed changes in a sector whose market signals are dominated by government-driven payment and regulation. The principal objective of this report, then, is to provide guidance for improving the quality enhancement processes of government health care programs. There have been numerous expert reports examining the quality activities of individual programs (Department of Defense, 2001; MedPAC, 2002). This committee was presented with a different challenge: to examine the quality enhancement processes of all six major government health care programs. The committee’s focus on multiple programs allows for the identification of opportunities to improve the effectiveness and efficiency of government quality oversight activities as a whole, as well as to make program-specific improvements. This focus also highlights the unique role the federal government can play in driving the redesign of the health care sector by leveraging its aggregate purchasing power. STUDY CONTEXT Quality of health care has become a significant concern of both public- and private-sector policy and program administration. For over two decades, there has been a steady flow of publications in leading peer-reviewed journals documenting widespread variability in quality (Jencks et al., 2000; Miller and Luft, 1993; Schuster et al., 1998). These gaps in quality are present for both capitated and fee-for-service insurance ar-

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Leadership by Example: Coordinating Government Roles in Improving Health Care Quality rangements and across all geographic areas and health care delivery settings (Chassin and Galvin, 1998). The convergence of a series of studies and reports beginning in 1998 has brought renewed urgency to the quality debate. These reports reveal widespread defects in the delivery of medical care that taken together “detract from the health, functioning, dignity, comfort, satisfaction, and resources of Americans” (Institute of Medicine, 2001, p. 2). According to the IOM’s National Roundtable on Health Care Quality: “The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering…. The challenge is to bring the full potential benefit of effective health care to all Americans while avoiding unneeded and harmful interventions and eliminating preventable complications of care…. Our present efforts resemble a team of engineers trying to break the sound barrier by tinkering with a Model T Ford” (Chassin and Galvin, 1998, p. 1004). The extent and impact of quality problems are confirmed in the report of the Advisory Commission on Consumer Protection and Quality in the Health Care Industry (Advisory Commission, 1998, p. 21): “[T]oday in America, there is no guarantee that any individual will receive high-quality care for any particular problem. The health care industry is plagued with overutilization … underutilization … and errors…. ” Results of studies of the treatment of specific diseases, such as cancers, indicate that serious quality problems emerge at virtually every stage of medical care (Institute of Medicine, 1999a). A lack of conformity with practice standards in the prevention, diagnosis, and treatment of disease is compounded by issues of basic patient safety in the delivery of care. Avoidable deaths due to medical errors exceed the number of deaths attributable to many leading causes of mortality, including AIDS, breast cancer, and motor vehicle crashes and injuries (Institute of Medicine, 1999b). In its report Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM (2001) calls for fundamental reform of the health care system directed at effecting substantial improvements to achieve six quality aims—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Achieving these aims will require changes at four levels: patient experiences, microsystems that deliver care (e.g., multidisciplinary team), health care organizations that house the microsystems (e.g., hospitals), and the environment (e.g., payment policies, regulatory framework) (Berwick, 2002). This steady stream of analyses, pronouncements, and consensus perspectives has created a national climate within which it is now expected that responsible health care programs will be accountable for demonstrating that the services they provide not only meet minimal standards of care quality, but also achieve continuous improvement. Major public- and

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Leadership by Example: Coordinating Government Roles in Improving Health Care Quality private-sector purchasers of care are demanding that steps be taken to improve the quality and safety of health care (Galvin, 2001). Because of the enormous influence of the six major government health care programs within the U.S. health care sector as a whole, the committee expects that these programs will attempt to address quality issues first, and most effectively. ORGANIZATION OF THE REPORT In this report, the committee responds to its charge by (a) describing the basic structure and beneficiary populations of the six major government health care programs, (b) documenting the activities of each of these programs with regard to the four principal components of quality enhancement identified above, and (c) offering recommendations for improving current quality enhancement processes. Chapter 2 provides a description of each of the six government health care programs included in this study. It also reviews the broad trends affecting the needs and expectations of the programs’ beneficiaries, as well as key program features other than quality enhancement processes that affect the quality of health care provided. Chapter 3 reviews the various roles played by the federal government in the health care arena and examines how these roles can be leveraged and better coordinated to improve the quality enhancement processes and activities of the various government health care programs. In general, each of the programs has fairly well-developed regulatory processes for ensuring quality, including minimum standards of participation for providers and external quality review activities. The federal government has far less experience as a value-based purchaser, although there are several notable examples of small-scale efforts to encourage disclosure of comparative quality data and selectively purchase from or provide payment incentives to high-quality providers. Lastly, three of the government programs—DOD TRICARE and the VHA and IHS programs—own and operate extensive delivery systems that have to varying degrees incorporated quality improvement activities into their operations. Chapter 4 proposes a national quality enhancement strategy focused on performance measurement that is based on standardized measures of clinical quality and patient perceptions of care—two areas that have in recent years received increased emphasis from all six programs. There are important similarities in the types of measures and approaches adopted by the various programs. The chapter stresses the need to develop standardized measures that address important priority areas and the importance of applying these standardized measures across all the government programs. Also examined are some of the methodological and operational

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Leadership by Example: Coordinating Government Roles in Improving Health Care Quality challenges that must be confronted, including measurement at the level of individual physicians/groups and accountability for quality concerns that cut across providers and settings. Chapter 5 calls for the federal government to work collaboratively with the private sector to establish processes for reporting, analyzing, and releasing performance measurement data. Under the national quality enhancement strategy recommended in this report, providers would submit performance data using standardized measures, and comparative performance data would be made available at various levels of detail to consumers, health care providers, purchasers, regulators, and other stakeholders. This chapter examines why a more sophisticated information infrastructure is critical both to the implementation of this quality enhancement strategy and to the achievement of threshold improvements in quality over the coming decade. It also explores the need for well-thoughtout processes for the analysis, interpretation, and release of performance data. Lastly, a strong health services research capability will be necessary to enable the establishment of standardized measures and public reporting functions across the various government health care programs. Chapter 6 provides an overview of current health services research activities related to quality oversight that are carried out by the various federal agencies. It also provides a rationale for a more coordinated process for development of a national health care quality research agenda. Three appendices are also included. Appendix A is a list of the acronyms used in the report. Appendix B shows the performance measurement set that resulted from the Diabetes Quality Improvement Project, an effort to develop a standardized set of process and outcome measures for performance reporting related to the care of adults with diabetes. Finally, Appendix C presents a technical overview of the health information systems of VHA and DOD. REFERENCES Advisory Commission. 1998. Quality First: Better Health Care for All Americans. Final Report to the President of the United States. Washington DC: U.S. Government Printing Office. Berwick, D. M. 2002. A user’s manual for the IOM’s “Quality Chasm Report”: patients’ experiences should be the fundamental source of the definition of “quality”. Health Aff (Millwood) 21 (1):80-90. Centers for Medicare and Medicaid Services. 2002. “National Health Expenditures Projections: 2001-2011.” Online. Available at http://www.hcfa.gov/stats/nhe-proj/proj2001/default.htm [accessed March 20, 2002]. Chassin, M., and R. Galvin. 1998. The urgent need to improve health care quality: Institute of Medicine National Roundtable on Quality. JAMA 280 (11):1000-05.

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Leadership by Example: Coordinating Government Roles in Improving Health Care Quality Department of Defense. 2001. “Healthcare Quality Initiatives Review Panel (HQIRP) Report.” Online. Available at http://www.tricare.osd.mil/downloads/FinalReport123.pdf [accessed June 26, 2002]. Galvin, R. 2001. The business case for quality. Health Aff (Millwood) 20 (6):57-58. Institute of Medicine. 1990. Medicare: A Strategy for Quality Assurance. Volume I. Washington DC: National Academy Press. ———. 1999a. Ensuring Quality Cancer Care. Washington DC: National Academy Press. ———. 1999b. To Err Is Human: Building a Safer Health System. Washington DC: National Academy Press. ———. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press. Jencks, S. F., T. Cuerdon, D. R. Burwen, B. Fleming, P. M. Houck, A. E. Kussmaul, D. S. Nilasena, D. L. Ordin, and D. R. Arday. 2000. Quality of medical care delivered to Medicare beneficiaries: A profile at state and national levels. JAMA 284 (13):1670-76. MedPAC. 2002. “Report to Congress: Applying Quality Improvement Standards in Medicare.” Online. Available at http://www.medpac.gov/publications/congressional_reports/jan2002_QualityImprovement.pdf [accessed Oct. 2, 2002]. Miller, R., and H. Luft. 1993. Managed care: past evidence and potential trends. Front Health Serv Manage 9 (3):3-37. Schuster, M. A., E. A. McGlynn, and R. H. Brook. 1998. How good is the quality of health care in the United States? Milbank Q 76 (4):517-63.