David F. Durenberger
I would like to begin with an explanation of the badge I am wearing. It is a picture of Jacob Wetterling, one of more than 4,000 children who have been abducted in recent years. Jacob was 11 years old when he was abducted about seven months ago. He was with his mother and his little brother on a rural road when the abductor, wearing a ski mask, took Jacob. They have not heard from him since.
We are talking about the quality of health care in America at this conference. If one defines health care in a comprehensive manner (as I think we must), the abduction is a quality-of-health care issue. Quality is a lot more than just what goes on in the doctor's office. It is doing something about the health problems that caused Jacob to be parted from his family.
It is hard to know where to start in responding to the Institute of Medicine (IOM, 1990) report other than with a compliment—and that is always a nice place to start. I think the effort of the committee is more than worthwhile; the product is very, very good. I hope it will be understood by many of my colleagues.
I trust that in the process of implementation, many sessions, like this conference, will be held to bring together people who are making growing contributions to our understanding of the quality assurance field. It is important that we keep using this kind of process, rather than just the political process, to implement quality assurance strategies.
As the person who accepts the responsibility for converting the Professional Standards Review Organization (PSRO) program to the Utilization and Quality Control Peer Review Organizations (PRO) program, I agree
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Medicare: New Directions in Quality Assurance 19 A Legislator's Response to the Institute of Medicine Report David F. Durenberger I would like to begin with an explanation of the badge I am wearing. It is a picture of Jacob Wetterling, one of more than 4,000 children who have been abducted in recent years. Jacob was 11 years old when he was abducted about seven months ago. He was with his mother and his little brother on a rural road when the abductor, wearing a ski mask, took Jacob. They have not heard from him since. We are talking about the quality of health care in America at this conference. If one defines health care in a comprehensive manner (as I think we must), the abduction is a quality-of-health care issue. Quality is a lot more than just what goes on in the doctor's office. It is doing something about the health problems that caused Jacob to be parted from his family. THE INSTITUTE OF MEDICINE REPORT It is hard to know where to start in responding to the Institute of Medicine (IOM, 1990) report other than with a compliment—and that is always a nice place to start. I think the effort of the committee is more than worthwhile; the product is very, very good. I hope it will be understood by many of my colleagues. I trust that in the process of implementation, many sessions, like this conference, will be held to bring together people who are making growing contributions to our understanding of the quality assurance field. It is important that we keep using this kind of process, rather than just the political process, to implement quality assurance strategies. As the person who accepts the responsibility for converting the Professional Standards Review Organization (PSRO) program to the Utilization and Quality Control Peer Review Organizations (PRO) program, I agree
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Medicare: New Directions in Quality Assurance with the comments in the summary of the committee's report about the need to build on and strengthen the existing PRO infrastructure for quality assurance. The criticisms noted in the summary on the PRO program are all appropriate, but I am not going to blame the individual PRO organizations for that. We in the Congress structured the program poorly and we, along with the Health Care Financing Administration, were negligent in attending to essential details. For example, we did not provide space for the individual PROs to breathe, grow, and adjust to reality at an individual state level as I intended when we first started the program. Thus, we now have a structure that gives primary attention to utilization rather than quality, focuses on outliers rather than the average provider, concentrates on inpatient care, imposes excessive burdens on providers, and does not use positive incentives to alter performance. It follows, of course, that almost every doctor perceives the program as adversarial and punitive. For the last five years or so, we have listened to similar complaints about the PROs without doing anything to correct the problems. The IOM critique is an accurate critique. Furthermore, the committee's conclusion to build on the infrastructure that is in place—to learn from what we know—is also an appropriate conclusion. I do not consider it my task today to comment in depth on the specifics of the 10-year implementation plan. I would like to make a general comment, however. The IOM and the study committee are to be complimented on the repeated emphasis in the implementation plan on the engagement of providers, patients, and consumers in quality assurance. That theme is present throughout the report. I agree with the importance of keeping the lines of communication and understanding open. ADDRESSING PROBLEMS OF UNDERUSE Problems of access and underuse are quality-of-care issues. However, the IOM was not charged by Congress through this study to focus on those problems. Thus, it is not a surprise that the report does not give equal attention to quality issues of the uninsured or underserved. Congress requested that the IOM undertake this study because of concern about the quality assurance program of Medicare—thinking in particular of the existing PRO program, which only monitors the quality of care provided or delivered to the Medicare beneficiary. The study was also supported by members of Congress who acknowledge that a price is paid for achieving advances in medicine: paying for new medical technology means less is available for the uninsured or underserved. We felt that we first needed to know how to assure the quality of care that is delivered; we needed to know how to determine if and where we are spending more than is necessary to have quality care.
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Medicare: New Directions in Quality Assurance Until we as a society come to grips with some basic issues of values, outcomes in health care, and quality of care, we will be limited in the resources we have available for health care. Special taxes such as tobacco taxes or liquor taxes will not solve the financing problem. We must confront our value system and determine if quality care can be provided more efficiently to those who are in the health care system. We can address the needs of the underserved only by closely examining where our monies are going now and by making the current health care delivery system more efficient and effective. FUTURE DIRECTION OF HEALTH POLICY I would like to make a few comments on where public policy is going in the future, some of which relate to this IOM study. I have recently completed working on the Pepper Commission (The National Bipartisan Commission on Comprehensive Health Care), which did not really solve any problems. In this country, health reform will take a fairly long time to define the problem before we define the solution in its larger sense. During this period we will be working on prospective pricing, outcomes measures, and practice guidelines. We will be conducting activities on an incremental basis similar to those recommended by IOM. We are not the revolutionaries; we are the reformers. Revolutionaries usually want to get things done quickly; that is not possible. The health policy reform process could possibly be speeded up through the multiple efforts of developed nations focusing on the same problems and thereby bringing about quicker solutions. The first step is to define the problem; that means we have to define health. We have to define health in the context of Jacob's abductor—in America we must approach health in the larger context. I am on the Finance Committee, the Labor and Human Resources Committee, and the Environment Committee. I am dealing with tax policy. I am also dealing with Medicare, with Medicaid, with maternal and child health, and even with Title XX (the Social Security Act); I am the author of several parts of the Clean Water and Clean Air Acts. I am also the author of the Safe Drinking Water Act and of legislation relating to leaking underground storage tanks. All of these are related to health—any place but in America. In America we have Medicare over here, the tax subsidy over there, and clean air someplace else. The only place they ever meet is in a room like this, where I can see the heads nodding in agreement. How are we going to redefine health? We will not be able to do so until the public and the political leadership in this country make up their minds that they are going to define health in different terms. I would hope that perhaps a year from now the President of the United States will make a
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Medicare: New Directions in Quality Assurance speech along this line, which will in effect help us to define health. We will then be in a position to begin the process of reforming our health policy. We cannot reform the components of the health care system—the medical, financial, or delivery parts of the system—until we all understand it in this much larger context. Nobody is going to give up what they have; each coalition has a narrow stake and the price is high. The reform process is going to have to confront a variety of issues. One of them is defining responsibility. Certainly if you have first-dollar health care coverage, you do not have any responsibility. You basically have a blank check. Most of us are aware that blank checks produce irresponsibility. So just defining responsibility in America in a new way is very, very important. Making a commitment to choice is also extremely important in this country. Freedom of choice promotes responsibility, affects outcomes, and is important to quality. By making choices we express our values. What is going on in Oregon1 must go on in Washington, D.C. We need a process of expressing and then implementing our societal values from time to time, and this is the place it has to go on. The folks in Oregon are just sending us a message. They are like Paul Revere and the lantern in the church steeple, but their message applies to all of us. A somewhat similar system must be put in place at the national level, but we can do it only if everybody in this country is willing to take responsibility—to step up and do something with their choices. The President talks about consumer choice in child care and in education, but he is going to have to add health care to the list. People are going to have to play a role in reforming the system. There is not one system of quality or value for everybody, even if there are national standards. Some things will be equal: access will be equal, information systems should be equally available to all, and the choices certainly ought to be fair. The financing mechanisms ought to be in place. I may make a different choice about health care than somebody else does. If I make the wrong choice, I ought to be penalized for it, and if I make the right one, I ought to be rewarded. This philosophy is so basic and essential to our American heritage, but we know that it is not applied in many public services. ASSURING QUALITY OF CARE IN THE FUTURE Who should be responsible for assuring quality of care in the future? I do not have any easy answers to that question. First, providers certainly 1 Editors' Note: A controversial approach being taken to expand Medicaid coverage by limiting the types of services the program will pay for.
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Medicare: New Directions in Quality Assurance would be the most reliable source to assure me of quality. Second, I would probably play a role in it as a consumer as well. Third, the people who currently should be playing a greater role in quality assurance are the employers of this country. We are at a point in time in which the company, in a sense, brings some level of comfort or assurance or security to a lot of people. Currently, however, they are the least well equipped to participate actively in health care quality assurance, even though they are exploring things such as case management and managed care. The employer's role is not yet developed. I think the employers of this country have an obligation—as yet unmet—not to provide coverage for a mandated set of benefits through health insurance (because I oppose that notion) but to deal with that important security relationship between management and labor. In so doing, the appropriate and very important role of employers in quality assurance will be more clearly defined. Insurance Reform The fourth place where we might find quality assurance is in what I would call the insurer of care management. This relates to what will be the next phase of my efforts to reform the health care system: oversimplified, I call it insurance reform. My link to the health insurance system today is a piece of paper that I buy from the Federal Employee Health Benefit Plan, which pays part of my bills. This system increases my insensitivity to my own responsibility and clouds my judgment about what it is I am buying. By insurance reform I mean that it is essential for us to define the product that we are putting on the market between the consumer and the provider. One product is insurance, catastrophic protection against catastrophic loss. That is an important product. If we have that protection, the other decisions we need to make, which presently are cloaked in health insurance, can be more wisely made. These other decisions (and the financing of them) have nothing to do with insurance per se. I am talking about decisions such as adopting personal life-styles for health promotion and disease prevention or, when you do get sick, deciding where to go, whose advice to take, and how much to pay for it. What role will a third-party payer play in financing those decisions? That is the undefined area, the area where we hope that care management and similar concepts will be part of the health policy reform package. I believe that it is appropriate at the national level to provide a basic health care service benefit package that reflects our national values. I do not know exactly what we as a society might include in such a benefit package—perhaps some health promotion and disease prevention services, some inpatient and outpatient services, and some mental health and chemi-
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Medicare: New Directions in Quality Assurance cal dependency services. I visualize that the basic benefit package would be subsidized in some manner and include some prescribed cost sharing. Any other health services purchased beyond the basic benefit covered package would be the individual's or employer's particular choice. Having a national-level benefit package means that all persons are covered, including those who may be heavy users of the health care system. This, in itself, would address many of the currently unresolved access problems for the uninsured or for those who have high-cost illnesses and diseases and are unable to obtain coverage for pre-existing conditions. My reform package begins with catastrophic coverage. We learned through the unsuccessful efforts to add catastrophic coverage to Medicare that we need to educate the public on what they are buying through insurance and to make them aware of what they are not buying. Americans need to understand the role they are playing—through purchasing insurance products with extensive benefit packages—in supporting and promoting the high cost of health care in America. The dissatisfaction with health care cost is as much my problem as a consumer as it is the problem of the insurance companies, the doctors, the hospitals, or anybody else. Until we, the consumers, understand that we are all part of the problem, we, the reformists, are not really going to be able to do all of the things we need to do to correct the problems. CLOSING REMARKS We need happy doctors in order to have quality care. Doctors must feel that they are doing what attracted them to practice medicine in the first place. For this to happen, the consumer—the patient—needs to better understand his or her role in the health care system. REFERENCE Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990.