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20
A Legislator's Response to the Institute of Medicine Report

J. Roy Rowland

May I tell you how pleased and honored I am to have been invited to be a part of this conference to discuss some of the work that you have been doing. I know that your charge was to look at the Medicare system and to think about quality assurance in that program, but one really cannot separate the Medicare system from the rest of health care delivery in our country, because what happens in one system is going to affect other systems. So, although the Institute of Medicine (IOM, 1990) report centered on the 30 million Americans who get their care through Medicare, I am very much concerned about the other 200-odd million people in the country and the quality of their care, and some of my remarks will reflect that broader concern.

ACCESS FOR MEDICARE ENROLLEES

When you talk about the quality of care for Medicare, are you talking about the quality of care for people who are eligible for Medicare, or are you talking about the quality of care for people who get into the system who are sick? Both of those need to be examined. If you look at the quality of care for people who are eligible for Medicare, who are not sick, I think it is important to realize that those people are very concerned about whether they are going to be able to get medical care when they need it. I hear this frequently at town meetings.

Most of these people, you say, have access to care if they are covered by Medicare. In listening to people in my district and elsewhere, I know that is not necessarily so. In fact, more recently I have been hearing from people who are concerned that they will not have a doctor when they need one. I am hearing more and more from physicians that they are not as



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Medicare: New Directions in Quality Assurance 20 A Legislator's Response to the Institute of Medicine Report J. Roy Rowland May I tell you how pleased and honored I am to have been invited to be a part of this conference to discuss some of the work that you have been doing. I know that your charge was to look at the Medicare system and to think about quality assurance in that program, but one really cannot separate the Medicare system from the rest of health care delivery in our country, because what happens in one system is going to affect other systems. So, although the Institute of Medicine (IOM, 1990) report centered on the 30 million Americans who get their care through Medicare, I am very much concerned about the other 200-odd million people in the country and the quality of their care, and some of my remarks will reflect that broader concern. ACCESS FOR MEDICARE ENROLLEES When you talk about the quality of care for Medicare, are you talking about the quality of care for people who are eligible for Medicare, or are you talking about the quality of care for people who get into the system who are sick? Both of those need to be examined. If you look at the quality of care for people who are eligible for Medicare, who are not sick, I think it is important to realize that those people are very concerned about whether they are going to be able to get medical care when they need it. I hear this frequently at town meetings. Most of these people, you say, have access to care if they are covered by Medicare. In listening to people in my district and elsewhere, I know that is not necessarily so. In fact, more recently I have been hearing from people who are concerned that they will not have a doctor when they need one. I am hearing more and more from physicians that they are not as

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Medicare: New Directions in Quality Assurance inclined to participate in the Medicare program as they were at one time, and this is causing a great deal of concern on the part of patients. Access to care is also affected by the cost of the care. Medicare is not a totally free program. There are some people for whom copayments and deductibles are a real hardship. If they are not eligible, if they are not at that specified income level where they become eligible for Medicaid to pay for their deductible and copayment, then they are somewhere in that gray area of never-never land, and they have trouble getting their copayment and deductible together. Just as you keep hearing that some 30 million Americans do not have any health insurance at all, when you talk about quality of care, you have to talk about the people who are eligible for care before they get sick and the concerns that they have. A COMPREHENSIVE STRATEGY I want to commend the Institute of Medicine (IOM) for the excellent study the committee and staff have done. Two very ambitious and challenging objectives have been laid out. The first is to establish a comprehensive theoretical framework for the development of quality assurance; the second is to implement an integrated strategy for improving the quality of care in the Medicare program. I am optimistic that Congress is going to work with this and is going to do the very best that it can to make some of these recommendations come true. Members of Congress will give a great deal of thought to it, because they are very concerned about a long-range strategy in health care, too. Nevertheless, a word of caution is needed. I think that Congress is afraid right now to be doing anything with our health care delivery programs after the catastrophic health insurance legislation (the Medicare Catastrophic Coverage Act of 1988) that we passed and then repealed under a barrage of objections. So, the members of Congress are somewhat wary right now about doing almost anything. CONCERN ABOUT COST CONTAINMENT AND MEDICARE I have been deeply concerned for some time about the Medicare program and our health care system in general, and in particular about the way that Medicare is influencing the practice of medicine and having mixed effects on our patients and our physicians. The constant budget cuts in Medicare over the last 10 years, which now total about $40 billion, have a considerable impact on the program. This has produced an undesirable context and frame of mind for the administration of this program. Efforts to assure quality of care and to maximize the value of enormous investments in our health care are most welcome. However, crude efforts to control utilization

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Medicare: New Directions in Quality Assurance or reduce payment just for the sake of cost containment represent a disregard for this program. In that regard, it is distressing to me to see the Congress go every year to the Medicare program to get money to meet the Gramm-Rudman-Hollings deficit reduction targets. Not only is this putting individual physicians and providers of health care in a bind, it is also putting hospitals in a terrible bind, particularly hospitals in rural areas and those teaching hospitals in urban areas that have a large number of Medicare patients. I called this morning to talk with a hospital administrator of the largest, not-for-profit hospital in my district. I knew that he was having a difficult time with respect to the Medicare program and that it was costing him money, and he gave me some figures that are astounding. The last five years have seen a steady loss of revenue from the Medicare program there. It is made up by shifting costs to the private sector. For 1989, there were 6,140 Medicare discharges from the Medical Center of Central Georgia, and his Medicare reimbursements relative to the cost of that care revealed a difference of over $30 million. Of course, he has to make that up. This cannot help but affect the quality of care adversely. Some of the people with whom I have talked in the Veterans Administration (VA) over the years say that the screws in the VA hospital and health care delivery system have been tightened more and more. Individual hospital directors have had increasing difficulty in meeting their responsibilities. It is natural and warranted for us to ask if these budget cuts adversely affect the quality of care available to the elderly, and I really think they do. The problem is that we are not in a position to answer that question empirically and authoritatively to prove what we sense is the case. We have not developed sufficient tools to evaluate the quality of care, and we do not have a baseline against which we can measure today's level of quality. Those factors go to the very heart of the matter, and they are one reason for the Congressional mandate for the IOM study. It is my hope and expectation that the study will finally put quality assurance for Medicare on the right track to be able to answer these very important questions. CONGRESSIONAL INTEREST We in the Congress are typically concerned with proposals to change the policies that structure the Medicare program. All too frequently we deal with these in an episodic, knee-jerk manner. We respond to pressures from our constituents. Often this response is very narrow, and we have been less attentive to evaluating implementation of these policies and trying to understand in a comprehensive manner how the administration of the program, including the interpretation and implementation of our policies, can either advance or derogate our good intentions.

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Medicare: New Directions in Quality Assurance The Subcommittee on Health and Environment (of the House Committee on Energy and Commerce) recently held a field hearing in Atlanta about Part B Medicare. The instigation for the hearing grew from problems encountered with medical review and utilization review after a rather abrupt changeover in Medicare carriers. It was apparent at the hearing, however, that the issue we were discussing was not just narrowly framed or local to the State of Georgia but was something that is pertinent to our whole country. We are hearing increasingly from patients and physicians that the program is too complicated, the rules are too arcane or obtuse, the red tape is too tightly wound, and the administration is really not responsive. The emphasis is too much on utilization control at the expense of quality assurance. The prevailing attitude seems to be one of finding a culprit rather than promoting efficient health care. Physicians and patients are complaining about the ''hassle factor'' and the difficulty of obtaining administrative remedies. CONCERNS ABOUT PRACTICING PHYSICIANS I used to be a practicing physician in Georgia, in family medicine, and I have seen how the practice environment has been changing. The complaints come not just from the few disgruntled or what we might call "bad actor" doctors. Rather, I know many physicians of very high caliber and great integrity who have been working to provide quality care in a compassionate manner. They are very distressed about what is taking place, and many of them are talking about dropping out of the Medicare program. Their complaints lie not in being inadequately paid, but rather in not being able to provide the care that they know is needed without having repeatedly to justify their decisions about the services they render. I received a copy of a letter just yesterday written by a doctor in Georgia to those in charge of the Medicare carrier program about some problems that he was having with a couple of patients in dealing with the Medicare program. One part caught my attention: "The next person has been my patient for 20 years after having had a myocardial infarction at a very early age. If your utilization system was more sensible and dealt with outcomes, I would get accolades for taking good care of him for two decades, helping him stay productively employed, out of the hospital, and on minimal medications." The phrase that really caught my eye was "if you...[had] dealt with outcomes...." So many times the powers that be do not deal with outcomes. They deal with something else, cost containment or whatever. The physicians I have been talking about have the knowledge that they need to practice good medicine, but they know there are some changes taking place in the environment. I saw my last patient in January 1982, and I was beginning to see some changes taking place then that I did not think

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Medicare: New Directions in Quality Assurance were in the best interest of quality. Physicians now are going to have to accept the legitimacy of the concerns about overutilization and ineffective care; there is some of that out there. They have to face the reality of cost containment, because whenever health care comes up at town meetings I hear about the inordinately high cost of medical care or particular things such as medications. However, these physicians need to be dealt with in a supportive and understanding manner. They need to be dealt with as colleagues and not as antagonists. Much of the IOM report discusses the current peer review program. It calls for a better balance between the task of catching so-called bad apples and the effort of improving the overall effectiveness of health care, and I agree with this. We will, of course, always need some watchdog function to screen out those who fail to meet an acceptable standard of competency or integrity. That will always create some level of contentiousness in the program. However, we should be putting greater emphasis on the potential for PROs to provide education and leadership for the improvement of health care. To realize this potential, we must invest more heavily in research, both basic and applied, to develop more sophisticated tools and better information. We need an applied technology for quality assurance. The IOM report has laid out a strategic framework for that, but a great deal of work must be done to develop specific criteria and standards and the data management systems necessary to carry it out. ADDITIONAL CONCERNS We took a giant stride forward last fall when we enacted legislation creating a new Agency for Health Care Policy and Research. We gave it a broader mission than its predecessor agency. We placed a special emphasis on patient-oriented, clinically based research, and we authorized the doubling of the resources previously devoted to these activities. I look to this agency to invest heavily in the promotion of the strategy laid out in the IOM report. Along with better information and tools, we also need to improve the professionalism of those with whom we entrust the task of quality assurance. I hear from physicians who are reviewed that they are reviewed by someone who really does not know a great deal about their particular area of medicine. For example, a neurosurgeon may be reviewed by somebody who practices obstetrics and gynecology. We need to do something to enhance the professionalism of people who are involved in the review process as well, including better training and enhanced stature. Maybe better career opportunities need to be considered.

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Medicare: New Directions in Quality Assurance CONGRESSIONAL RESPONSIBILITY I expect the Congress to respond favorably to this report. The role and responsibility of the Congress at this point is clear. First, we must articulate clear objectives and priorities for quality and quality assurance in the Medicare program and lay out a long-range strategy for that achievement. Second, we must provide adequate resources to implement that strategy. In this era of cost containment, there is a serious risk of underfunding the administration of the program generally and quality assurance, in particular. This would be a serious mistake. Here, as in so many things, we will get what we pay for. Third, we must hold parties accountable much more than we have in the past for carrying out quality assurance provisions properly and for providing quality care throughout the program. Those are some of the thoughts I have about what is going on in our system. I appreciate what you have done in focusing on quality in our Medicare system. You have done a great work here, and I am happy to be a part of this challenging product. 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.