Medicare: New Directions in Quality Assurance Proceedings (1991)

Jerome H. Grossman

At the beginning of the conference Steven Schroeder (Schroeder, 1991) asked whether we were going to launch the ship. I am here with a bottle of champagne, and we are going to crack it over the bow of this ship as we put it in the water. This is a terrific report (IOM, 1990). It is the only one I have read that gets better each time I read it. Why does it get better? I think that it comes at a particular moment, and it does two very important things. First, it offers the basis of what I would call a mid-course correction in the Medicare program. It has the intellectual base that brings together what has been fermenting, and it incorporates the beginnings of cultural change in the last decade and gives them form and substance.

Second, the report gives a specific set of recommendations and a program for implementation that I think superbly reflect the realities of public program and government operation. When people ask whether we should just tinker and work on the margins, my answer is no. I would never have said that five or ten years ago. I now understand that there is a legislative and administrative context in which to carry out a program.

With that as background or overview, you may be asking, "Where do we go from here?" The answer is that there are buses outside with placards and lists of Congress people. Each of you will be ending up with a small walk around the White House at four o'clock.

These Institute of Medicine (IOM) findings (and recommendations) need to be distributed, reviewed, corroborated, supported, and altered by the critical groups out there. I will come back to this a little bit later. Furthermore, with appropriate corroboration and support, a consortium of parties needs to

come together to press for the legislative and administrative changes called for.

Why should such an effort be undertaken? If it is undertaken, will it succeed? Why should it be supported? I think the shift of definition of purpose—to achieving outcomes for patients—is very important. It needs to be understood, internalized, and externalized, and I have come to understand that this shift in purpose represents a major cultural change. It does not come overnight. It does not come because we all sit here and agree with one another. The changes need a broad and public appreciation and understanding.

The shift to outcomes is not just a technical process. The more I look at this, the more I think we have been obsessed in this country with reducing risk through accuracy and data collection. We have gotten so carried away that we believe that if it is not measurable, it is not real. The fact that we now have outcomes and health status measures that are broader than our physiologic measures is, I think, critical to our ability to make the shift to a broader definition of quality and outcome. We can measure things now—accurately, reliably, and repeatedly—that simply were not available in the past to be measured and incorporated into a quality assurance effort.

Within the issue of outcomes, functional status, and satisfaction is another critical shift—namely, a redressing of the balance between those of us who give care and those of us who receive it. There must be a growing understanding that this is a partnership and that we cannot do it alone. Patient preferences, patient control, and levels of patient compliance do affect outcomes. That is one important theme that must be more broadly understood as well as written into legislation.

I believe that we need to understand the culture of physicians and hospitals with the objective of getting medical care providers to internalize this broader view of their objectives and roles. Someone asked whether hospitals were willing to look at outcomes. I must say I was a bit taken aback by that. I think many of us have been struggling with it as our purpose for being here. Some might resist, but I cannot imagine that they are very many in number.

The report calls for re-recognizing the role of the professional, re-recognizing some assumptions that people do have positive, virtuous goals. Yes, there are ''bad apples,'' but let us not concentrate all of our time and energy on them because as Relman (1991) says, "We have a lot of sullen people

out there." They are sullen because every morning they wake up, and they think someone is saying, "We know you are committing fraud and abuse. We just have to find out how you're doing it and how much you're doing it." In appealing to providers of care we also need to understand that we tend to like trendy work. During the conference discussions someone suggested that this notion of continuous quality improvement has the feel of a religion. It does to some extent, but that does not make it any less valid. I know we cannot get it written into legislation if it is a religion, so we call it something else.

One characteristic of past strategies has been an unrelenting focus on cost containment, to which I would add "unrelenting but unsuccessful focus on cost containment." In some way, the suggestions and findings of this report reflect what we are learning in American society. Namely, you must keep in mind the long run; you have to be looking out for the long haul. Investment in quality is the lowest cost way of achieving improved health status outcomes. My view of what is proposed here represents the best strategy for cost containment as well as for improved outcomes that we presently have.

How do we make the transition? I have learned that you can have wonderful ideas about what happens ten years from now, but you also have to stay in business every year. We learned that at the Harvard Community Health Plan. I was its first employee. We started it with wonderful ideas about what it should be. In 1969 when we opened, we had the staff ready to take care of 10,000 people. We had fewer than 100 sign up. We had just a little excess capacity, and we lost big, big dollars. So, we have to understand that we have to get from here to there while making it through this—and every—year. I think the IOM committee's ideas about 10 years, about transition, and about mid-course corrections offer just the right tone and reality.

The report and the conference discussion also featured research, training, and capacity building. To me, this is part of another general theme. We have done a terrific job in this country on physiologic and biologic research. This last decade makes the previous ones look like small potatoes. The wonderful results that will come out of current molecular biology and genetics research are glorious stuff.

We forgot, however, to do the second half of research and development (R&D). Palmer (1991) says it so well: how the system is organized and

operated needs the same R&D—the same phases of implementation, evaluation, and correction. We have done almost no work to bring either the hard or the soft social sciences to stand side by side with what we do in academic medicine. In Japan and in Europe, advances in techniques of production belong to the private sector. In the United States, we do not have a private sector that is sufficiently organized to have that sort of dedication. It is either in the public domain or, in our wonderfully American way, in the voluntary, not-for-profit, academic, collegial environment where we do this work. This begins to focus on that incredibly important piece of work that we are just beginning to do, to improve our understanding of the production process and to make it a more receptive environment for the quality management process.

The question I would then turn to is whether this plan and this methodology are intellectually sound. There is no doubt about that. We talked about that at this conference, and I heard no one disagree on that point. Is this approach practical? That clearly comes next. My strong belief is that it is and that it needs to be done. Medicare is a program that has enormous implications beyond itself. It sets national standards. What we do here inevitably affects the tone and quality of life in American medicine. My understanding is that the Health Care Financing Administration (HCFA) says, "Well, we're really doing this stuff already. We don't need legislation, we don't need another 'PAC smack,' another commission. All these people just bother us—let's have smaller government and get on with it." I say no, there is another overarching theme here, and that is that we can no longer be adversarial. It is indeed "getting to yes," and we need all the parties at the table. Both of the proposed entities (QualPAC and the National Council)¹ have the potential to bring together around the same table those who receive, those who provide, and those who pay for care.

Computer systems have allowed us to create computer star wars. With the current "system"² the providers sit there while the payers lob 800-

numbers at us. They have their people at their green screens. What do you think that we have—our people at our green screens. If it is this 800-number, this is the right answer. They find that they are not denying enough so they have to change their questions, right? And our guys are sitting there trying to figure out how can I get the next right answer? Well, this is hopeless; it just will not work. The practical utility here is indeed bringing together the parties. Why is the timing so good for this? Because we have reached a magic moment: everybody is miserable.

It took us time, but now we are there. It has got to be better to sit down and talk than to keep going on this way. This report represents a very thoughtful way of bringing those parties together to have that discussion, because while my view of quality and your view of quality and my view of outcomes and yours may be different, we now have the methods, the ability, and the desire to get some resolution. Each of these proposed councils represents a vehicle to send out a very important cultural message.

Gosfield (1991) discusses guidelines, due process, and the scientific method. The development of guidelines really is due process because there is not any scientific basis for developing them. It is due process in which all the parties come together and talk about what they think is appropriate and how it might be done. Until we have the scientific basis, until this research really turns out work 5, 10, and 15 years from now, we need to come to agreement about what we are going to try, the basis on which we are going to try it, and how we are going to assess how it is working. That is a critical part of the agenda. As you propose here, we need to resist the definition of guidelines as part of the process and create the organizational framework in which to carry out these discussions. You set out some principles that bring appropriate methodology and reprofessionalize the process around the organizations, their implementation, evaluation, and correction.

Finally, the IOM highlights the need to conduct sponsored research, to build appropriate capacity, and to train appropriate people. There is a wonderful analogy to the National Institutes of Health. We do not hear about the success of government-sponsored research and training efforts, but we do hear about wonderful science. I do not have any doubt that we can also do wonderful work in the social and behavioral sciences and in the science of management and organization. It will be enormously less expensive than biologic research, and we are on the way, building on efforts begun in the last decade or so. Like that research, it will be supported by a combination of public and private funding. I am less worried about course development and its sponsorship because I think it is attracting good people already.

To build on Heather Palmer's comment, what attracts someone to a career in this research is some belief that 5, 10, or 20 years from now, he or she can continue that career. It is more than the dollars themselves. The

continuous funding of this work at an appropriate level is what will attract the best and brightest to that career, and that kind of funding probably has to be public. The mandate has to be there and exist by law, as I think it is beginning to do.

I will end as I started, with my affirmation of the IOM's good work. I have my champagne bottle to break across the bow of the bus that we are all going to get on to head up to Congress to get this work done.

Gosfield, A.G. Legal Concerns. Pp. 105-115 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.

Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990.

Palmer, R.H. The Epidemiology of Quality Problems. Pp. 96-104 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.

Relman, A.S. A Physician's Response to the Institute of Medicine Report. Pp. 167-173 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.

Schroeder, S.A. The Institute of Medicine Report. Pp. 7-14 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.