Informing the Future: Critical Issues in Health: Fourth Edition (2007)

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Quality of care: A Health Professional Duty Quality of Care: A Health Professional Duty Health care is a vast enterprise that now accounts for more than one in ev- ery seven dollars spent in the U.S. economy. Despite spending that dwarfs that of every other country in the world, more than 15 percent of Americans had no health care insurance in 2005, and the United States lags behind dozens of other nations on health measures such as infant mortality and life expectancy. Despite striking scientific advances and new therapies, too often the quality of care that every citizen deserves is not delivered. Is it possible to attain a high-quality health system that functions well for every American and that is efficient and affordable in its operation? How will the nation cope as new technologies and an aging population add to the pressures on the system? To help answer these questions, the Institute of Medicine (IOM) has focused on a fundamental triad of interdependent goals for improving the U.S. health system: access, quality, and cost of care. The IOM’s recent work in this area in- cludes proposals to reform the system of payment so as to improve both the ef- ficiency and quality of care in America, to face up to the problem of the stressed emergency care system, and to improve tools for decisions in the Social Security disability process. Reforming Payment In 2006, Medicare provided more than $300 billion in health care benefits to more than 42 million Americans. Yet this massive expenditure provided health security for only a fraction of U.S. citizens and optimal care for fewer still. Medicare—and most private insurance—reimburses providers for the in- dividual services delivered to treat injury and illness, but it does not provide comprehensive coverage. By focusing on individual treatments, Medicare does not pay for coordination of care for patients whose health care involves multiple providers, nor does it offer incentives to improve patients’ overall health over time. Each of these deficiencies is a roadblock on the path to quality health care. To address these problems, Congress turned to the IOM for strategies for change, which resulted in a series of studies Pathways to Quality Health Care (2006).  

Informing the Future: Critical Issues in Health The first report in the series, Performance Measurement: Accelerating Improve- ment (2006), reviewed the available measures of health care performance that could be used for public reporting and recommended principles for a national measurement and reporting system. The second report, Medicare’s Quality Improve- ment Organization Program: Maximizing Potential (2006), offered ways to strength- en the technical assistance function of Medicare’s Quality Improvement Organi- zations so that all providers are ready to provide the highest quality of care. The third and final report, Rewarding Provider Performance: Aligning Incentives in Medicare (2007), took an important step further by analyzing the risks and benefits of instituting a pay-for- performance program within Medicare to encourage a more value-driven health care system. If implemented, pay for performance would fundamental- ly change the way Medicare works. Currently, the reimburse- ment system encourages quantity of care (performing more procedures) rather than quality (keeping patients healthy). The third report acknowledged that changing the prac- tice patterns of America’s physicians is a huge challenge. Most physicians practice in small groups of two or three and lack the economies of scale necessary for optimal quality and TABLE 1-1 Estimated Medicare and National Health Expenditures, 1975–2004 1975 1985 1995 2004 Increase (billions (billions (billions (billions 1975–2004 Expenditures of dollars) of dollars) of dollars) of dollars) (percent) Medicare 16.3 71.4 182.4 309.0 1,796 National health expenditures 133.6 441.9 1,020.4 1,877.6 1,305 Medicare expenditures as percentage of national health expenditures 12.2 16.2 17.9 16.5 35 SOURCE: CMS, 2006. Estimated Medicare and National Health Expenditures, 1975–2004. SOURCE: Rewarding Provider Performance, p. 24.  

Quality of Care: A Health Professional Duty efficiency improvements. The options and rec- In 2006, Medicare provided more ommendations presented in the report discussed than $300 billion in health care the implementation of such a program in stages benefits to more than 42 million to improve the return on health care investments. Americans. Yet this massive Although focused on Medicare, the report has expenditure provided health security many applications for payers and consumers in for only a fraction of U.S. citizens and the private sector. Since the final report’s release, optimal care for fewer still. the New England Journal of Medicine has published a number of articles that explore the implications of its recommendations. Medicare needs incentives to promote better health outcomes as well as better quality and efficiency in services. Pay for performance creates these incen- tives, encouraging improved quality and value. To promote the participation of as many health care providers as possible, the program should reward those who improve their performance significantly, as well as those who meet or exceed designated thresholds of excellence. Fixing Emergency Medical Services The United States is facing a national crisis in emergency care. The nation’s emergency and trauma care system has made tremendous strides over the past few decades, but insufficient funding and uncompensated care have sapped its capacity. Despite the heroic, lifesaving feats performed every day by individu- als in emergency departments (EDs) and ambulance services, the nation’s emer- gency medical system as a whole is overburdened, underfunded, and highly fragmented. The precarious state of emergency care is documented in the IOM’s three-re- port series Future of Emergency Care (2007). The facts are startling: ambulances are turned away from emergency departments once every minute, and ED patients admitted to the hospital often wait hours or even days for an in-patient bed. Already strained by routine care, the system is ill-prepared to handle surges from disasters. A hurricane, terrorist attack, or disease outbreak—even a fire in an of- fice building—can quickly overwhelm a local ED. The IOM Committee on Emergency Care was convened in 2003 to examine the state of emergency care in the United States, to create a vision for the future of emergency and trauma care, and to make recommendations to help the nation achieve that vision. It recommended that Congress allocate significant funds to ensure that America’s emergency departments, trauma centers, and medical first  

Informing the Future: Critical Issues in Health responders are fully equipped and ready to provide prompt and appropriate care. The committee also called for action to reduce crowding in emergency rooms, boost the number of specialists involved in emergency care, and create collabo- ration between all emergency medical services in a geographical area to ensure that patients are sent to the most appropriate . . . ambulances are turned away from facilities. Immediately, professional societies and emergency departments once every news groups responded to the alarm sounded by minute, and ED patients admitted to these reports, convening symposia and providing the hospital often wait hours or even thorough media coverage. Recently, legislation days for an in-patient bed. based on the committee’s recommendations has been introduced in Congress by Senator Barack Obama. Hospital-Based Emergency Care: At the Breaking Point (2007) explored the chang- ing role of the hospital emergency department and the national epidemic of overcrowded EDs and trauma centers. In 2003, emergency departments received nearly 114 million patients—a 26 percent increase over the past decade, but dur- ing the same period, the United States suffered a net loss of 703 hospitals and 425 emergency departments. Number of Hospitals Reporting ED Visits versus Increase in ED Visits 5,000 120.0 4,500 100.0 4,000 Hospitals Reporting ED Visits 3,500 80.0 ED Visits (millions) 3,000 2,500 60.0 2,000 1,500 40.0 1,000 20.0 500 0 0.0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Total U.S. Hospitals Reporting ED Visits Total ED Visits (millions) Hospital EDs versus ED visits. SOURCE: Hospital-Based Emergency Care: At the Breaking Point, p. 38. 2-1 New  April10 

Quality of Care: A Health Professional Duty The wide range of issues covered in this report included • the role and impact of the emergency department within the larger hos- pital and health care system; • patient flow and information technology; • workforce issues across multiple disciplines; • patient safety and the quality and efficiency of emergency care services; • basic, clinical, and health services research relevant to emergency care; and • the special challenges of emergency care in rural settings. Emergency Medical Services at the Crossroads (2007) described the development of emergency medical services (EMS) systems over the past 40 years—the roots of the fragmented structure that exists today. Ambulances were diverted 501,000 times in 2003 because of overcrowded EDs. EMS agencies do not effectively coor- dinate services with EDs and trauma centers, which results in poor management of the regional flow of patients. To address the strengths, limitations, and future chal- lenges of EMS, this report examined • the evolving role of EMS as an integral component of the overall health care system; • EMS system planning, preparedness, and coordina- tion at the federal, state, and local levels; • EMS funding and infrastructure investments; • EMS workforce trends and professional education; and • EMS research priorities and funding. Emergency Care for Children: Growing Pains (2007) detailed the unique challenges of providing critical care for injured and seriously ill children. The nation’s emergency care system is not well pre- pared to handle seriously ill or injured pediatric patients. Although children make up more than a quarter of all ED and trauma patients, only 6 percent of hospital EDs have all the supplies deemed essential for managing pediatric emergencies. The report analyzed the U.S. emergency care system with specific regard to • the role of pediatric emergency services as an integrated component of the overall health system;  

Informing the Future: Critical Issues in Health 60 50 Percent of Pediatric ED Visits 40 30 20 10 0 Under age 1 Ages 1–4 Ages 5–12 Ages 13–18 Private Medicaid/SCHIP Percentage of pediatric ED visits covered by private insurance or Medicaid/State Children’s Health Insurance Program (SCHIP). SOURCE: Emergency Care for Children: Growing Pains, p. 68. 2-5 • system-wide pediatric emergency care planning, preparedness, coordi- nation, and funding; • pediatric training in professional education; and • research in pediatric emergency care. Making Better Decisions The challenge of funding Social Security retirement benefits for “Baby Boom- ers” is well known. Less understood is the more immediate and severe challenge facing the Social Security disability benefits system. Approximately 2.5 million people apply for disability benefits each year. The Social Security Administration (SSA) expects the number of Social Security Disability Insurance (SSDI) beneficia- ries to increase by 26 percent between 2005 and 2015. While this sharp increase in SSDI applications has many root causes, the insurance crisis is a significant and little-examined driver: SSDI status brings with it eligibility for Medicare. In order to receive benefits, adult applicants for SSDI must be evaluated for their ability to work. The SSA uses a time-saving medical screening tool called the Listing of Impairments (the Listings) to identify individuals who meet the Social 10 

Quality of Care: A Health Professional Duty 60% SSDI-only 50% SSDI/SSI SSI-only Adult Percentage of All Awards 40% SSI Child 30% 20% 10% 0% n l r al s y e ry ta la m or tio in et to en cu as cr ns da el ra m as do sk pl se pi ar eo ov er En es lo s/ et cu th di N u R R vo O ar us C er M N Diagnostic Group Distribution of initial awards of Social Security disability benefits among program and selected di- agnostic groups, 2004 (percentage of all awards). SOURCE: Improving the Social Security Disability Decision Process, p. 40. fig 3-2 Security definition of disability. If the Listings work effectively, a high percent- age of individuals who meet the SSA definition of disability are identified in the initial evaluation. If the Listings are out of date, a high proportion of those who will eventually be found eligible are deemed ineligible in initial screenings. This launches a lengthy and expensive appeals and reconsideration process. The SSA is concerned that because of the inaccuracies in the existing system, too many applicants are initially rejected, and costs are increased while quality and timeli- ness of care decrease. At the request of the SSA, the IOM formed a committee to study the issue. Its report, Improving the Social Security Disability Decision Process (2007), addressed the medical aspects of disability determination and recommended improvements. Specifically, the report recommended that the SSA investigate the reliability and validity of the Listings as a tool for identifying the truly disabled and incor- porate condition-specific functional assessment tools that demonstrate a strong correlation with work disability. It also recommended that the SSA strengthen 11 

Informing the Future: Critical Issues in Health the process for revising and updating the Listings, including expanding medical and functional expertise at the staff level as well as establishing an external advi- sory committee system. The committee advised . . . a streamlined assignment of SSDI partnering with other concerned agencies to benefits to those in need will provide conduct surveys and research on the population timelier access to care. Earlier care is, of persons with disabilities. The committee con- almost always, both better and more cluded that no better mechanism than the List- cost-effective. ings exists at this time, but it recommended that SSA monitor and support promising alternative approaches to disability assessment. Improve- ments to, and continuous updates of, the Listings will provide applicants with faster, more accurate determinations, thereby reducing administrative costs for SSA. More importantly, a streamlined assignment of SSDI benefits to those in need will provide timelier access to care. Earlier care is, almost always, both bet- ter and more cost-effective. 12