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MEDICARE

New Directions in Quality Assurance

Proceedings of an Invitational Conference by the INSTITUTE OF MEDICINE

Division of Health Care Services

Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr, editors

NATIONAL ACADEMY PRESS
Washington D. C.
1991



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Medicare: New Directions in Quality Assurance MEDICARE New Directions in Quality Assurance Proceedings of an Invitational Conference by the INSTITUTE OF MEDICINE Division of Health Care Services Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr, editors NATIONAL ACADEMY PRESS Washington D. C. 1991

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Medicare: New Directions in Quality Assurance NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competencies and with regard for appropriate balance. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This conference was supported by the Health Care Financing Administration, U.S. Department of Health and Human Services, under Cooperative Agreement No. 17-C-99170/3. Library of Congress Catalog Card No. 90-63821 International Standard Book Number 0-309-04429-4 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 S274 Printed in the United States of America

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Medicare: New Directions in Quality Assurance COMMITTEE TO DESIGN A STRATEGY FOR QUALITY REVIEW AND ASSURANCE IN MEDICARE STEVEN A. SCHROEDER, Chair, Chief, Division of General Internal Medicine, University of California, San Francisco, California MARK R. CHASSIN, Value Health Sciences, Santa Monica, California LEO M. COONEY, Jr., Yale University School of Medicine and Yale-New Haven Hospital, New Haven, Connecticut ROBERT B. COPELAND, Georgia Heart Clinic, LaGrange, Georgia CHARLES J. FAHEY, Third Age Center, Fordham University, New York, New York PAUL F. GRINER, University of Rochester Medical Center and Strong Memorial Hospital, Rochester, New York WILLIAM S. HOFFMAN, Social Security Department, International Union, United Auto Workers, Detroit, Michigan ROBERT L. KANE, School of Public Health, University of Minnesota, Minneapolis, Minnesota HAROLD S. LUFT, Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California MAXWELL J. MEHLMAN, The Law-Medicine Center, Case Western Reserve University School of Law, Cleveland, Ohio MARIE MICHNICH, American College of Cardiology, Bethesda, Maryland MARILYN MOON, Public Policy Institute, American Association of Retired Persons, Washington, D.C. JAMES D. MORTIMER, Midwest Business Group on Health, Chicago, Illinois ALBERT G. MULLEY, Jr., General Internal Medicine Unit, Massachusetts General Hospital, Boston, Massachusetts EDWARD B. PERRIN, Department of Health Services, University of Washington, Seattle, Washington MARGARET D. SOVIE, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania LORING W. WOOD, NYNEX Corporation, White Plains, New York

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Medicare: New Directions in Quality Assurance STUDY STAFF Division of Health Care Services KARL D. YORDY, Director KATHLEEN N. LOHR, Study Director MOLLA S. DONALDSON, Associate Study Director JO HARRIS-WEHLING, Staff Officer ALLISON J. WALKER, Research Associate H. DONALD TILLER, Administrative Assistant THELMA COX, Senior Secretary THERESA NALLY, Senior Secretary

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Medicare: New Directions in Quality Assurance Acknowledgments The contributions of several members of the Institute of Medicine staff deserve special mention. Theresa Nally, Senior Secretary for the project, both assisted with the conference and prepared the manuscript. Thelma Cox, Project Secretary, H. Donald Tiller, Administrative Assistant, Allison J. Walker, Research Associate on the study, and Wallace K. Waterfall, Director of the Office of Communications, also provided valuable assistance. The consistent and generous support of Karl D. Yordy, Director of the Division of Health Care Services, deserves special mention. Support for the study was provided by the U.S. Department of Health and Human Services, Health Care Financing Administration. We acknowledge the assistance of the government's project officer, Harry L. Savitt of the Office of Research and Demonstrations. The Institute of Medicine provided partial support for this monograph through its discretionary funds.

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Medicare: New Directions in Quality Assurance Contents ACKNOWLEDGMENTS   v PART I: INTRODUCTION     1.   Introduction Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr   3 2.   The Institute of Medicine Report Steven A. Schroeder   7 PART II: NEW DIRECTIONS: MORE PROFESSIONALISM, LESS REGULATIONS William S. Hoffman   17 3.   The Committee View Leo M. Cooney, Jr.   18 4.   A Response Lonnie R. Bristow   22 PART III: NEW DIRECTIONS: ORGANIZATION- AND SYSTEM- FOCUSED QUALITY IMPROVEMENT Loring W. Wood   29 5.   The Committee View James D. Mortimer   31 6.   A Response Chip Caldwell   37

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Medicare: New Directions in Quality Assurance PART IV: NEW DIRECTIONS: IMPROVED DECISIONMAKING BY PATIENTS AND CLINICIANS Robert B. Copeland   47 7.   The Committee View Paul F. Griner   48 8.   A Response John Rother   54 PART V: NEW DIRECTIONS: A PATIENT OUTCOMES ORIENTATION Charles J. Fahey   61 9.   The Committee View Albert G. Mulley, Jr.   63 10.   A Response John E. Wennberg   73 PART VI: NEW DIRECTIONS: PUBLIC ACCOUNTABILITY AND PROGRAM EVALUATION Marilyn Moon   81 11.   The Committee View Maxwell J. Mehlman   82 12.   A Response Duncan vB. Neuhauser   86 PART VII: CONFRONTING SPECIAL IMPLEMENTATION ISSUES Mark R. Chassin   93 13.   The Epidemiology of Quality Problems R. Heather Palmer   96 14.   Legal Concerns Alice G. Gosfield   105 15.   Translating the Institute of Medicine Report Strategy Beyond Medicare James S. Roberts   116 Part VIII: NEW DIRECTIONS: THE RESEARCH, TRAINING, AND CAPACITY, BUILDING AGENDAS Edward B. Perrin   129 16.   Research and Capacity Building: Issues Raised by the Institute of Medicine Report Harold S. Luft   130 17.   The Research Agenda: An Outside View Sheldon Greenfield   140

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Medicare: New Directions in Quality Assurance 18.   The Training and Capacity Building Agendas: An Outside View Edward W. Hook   145 PART IX: RESPONSES TO THE INSTITUTE OF MEDICINE REPORT RECOMMENDATIONS Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr   153 19.   A Legislator's Response to the Institute of Medicine Report David F. Durenberger   155 20.   A Legislator's Response to the Institute of Medicine Report J. Roy Rowland   161 21.   A Physician's Response to the Institute of Medicine Report Arnold S. Relman   167 22.   An Administration Response to the Institute of Medicine Report From the Agency for Health Care Policy and Research Linda K. Demlo   174 23.   An Administration Response to the Institute of Medicine Report From the Health Care Financing Administration Thomas G. Morford   179 24.   A Peer Review Organization Response to the Institute of Medicine Report William H. Moncrief, Jr.   186 PART X: WHERE DO WE GO FROM HERE? Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr   193 25.   Where Do We Go From Here? Ceylon S. Lewis, Jr.   194 26.   Where Do We Go From Here? Jerome H. Grossman   198

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