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Introduction

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

QUALITY OF CARE AND QUALITY ASSURANCE FOR MEDICARE

At the twenty-fifth anniversary of the Medicare program, the Congress of the United States, the executive branch of the federal government, and indeed the entire country can be justifiably proud of the accomplishments of the program in expanding access to a generally high level of quality of care for the elderly. Near universal coverage by the Medicare program gives elderly people better access to health care than any other age group. Nevertheless, care is neither uniformly accessible nor uniformly good. Excessive care, underuse of services, and care of poor technical or interpersonal quality in hospital, office, and community settings continue to be reported. Some quality problems may be related to gaps or inadequacies in Medicare coverage.

Almost from the beginning, the federal government has tried to ensure that services reimbursed through the Medicare program are medically necessary, appropriate, and of a quality that meets professionally established standards. The two main efforts in this arena have been the Professional Standards Review Organizations (PSROs), in operation between 1972 and 1981, and the Utilization and Quality Control Peer Review Organization (PRO) program in operation since then. The success of those programs in meeting goals has been mixed, at best.

Since the implementation of Medicare's Diagnosis-Related Group (DRG) based prospective payment system (PPS) for hospitals in 1983, Congress has heard from many quarters that the quality of health care was being (or would be) undermined. To date, however, few data support or refute such claims.



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Medicare: New Directions in Quality Assurance 1 Introduction Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr QUALITY OF CARE AND QUALITY ASSURANCE FOR MEDICARE At the twenty-fifth anniversary of the Medicare program, the Congress of the United States, the executive branch of the federal government, and indeed the entire country can be justifiably proud of the accomplishments of the program in expanding access to a generally high level of quality of care for the elderly. Near universal coverage by the Medicare program gives elderly people better access to health care than any other age group. Nevertheless, care is neither uniformly accessible nor uniformly good. Excessive care, underuse of services, and care of poor technical or interpersonal quality in hospital, office, and community settings continue to be reported. Some quality problems may be related to gaps or inadequacies in Medicare coverage. Almost from the beginning, the federal government has tried to ensure that services reimbursed through the Medicare program are medically necessary, appropriate, and of a quality that meets professionally established standards. The two main efforts in this arena have been the Professional Standards Review Organizations (PSROs), in operation between 1972 and 1981, and the Utilization and Quality Control Peer Review Organization (PRO) program in operation since then. The success of those programs in meeting goals has been mixed, at best. Since the implementation of Medicare's Diagnosis-Related Group (DRG) based prospective payment system (PPS) for hospitals in 1983, Congress has heard from many quarters that the quality of health care was being (or would be) undermined. To date, however, few data support or refute such claims.

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Medicare: New Directions in Quality Assurance In response to the concerns that quality of care might be deteriorating under PPS and that the PROs and other mechanisms for monitoring quality were inadequate, Congress included in the Omnibus Budget Reconciliation Act of 1986 a provision that directed the Department of Health and Human Services (DHHS) to request that the National Academy of Sciences ''design a strategy for quality review and assurance in Medicare.'' THE INSTITUTE OF MEDICINE STUDY In 1987, therefore, the Institute of Medicine (IOM) of the National Academy of Sciences appointed a committee to conduct the requested study, with funding from the Health Care Financing Administration (HCFA). The study committee interpreted the congressional charge as a call for a far-reaching strategic plan for developing a program throughout the next decade for assessing and ensuring the quality of medical care for elderly people. In March 1990 the IOM released the committee's two-volume report Medicare: A Strategy for Quality Assurance.1 Volume I contains the IOM committee's recommendations for a comprehensive quality assessment and assurance strategy for Medicare. Volume II includes an extensive compilation of available information on quality measurement and assurance, and makes available many of the background technical analyses that supported the committee's deliberations. The report concluded that the current Medicare system to assess and ensure quality is not very effective and may have serious unintended consequences. It pointed out, however, that opportunities are now emerging to set in place a comprehensive system of quality assurance that can address itself to improving the health of U. S. citizens. The committee articulated several themes as the basis for the major redirection for a quality assurance program for Medicare. These included enhancing professionalism, strengthening organizational systems for quality improvement, improving patient and practitioner decisionmaking, introducing a patient outcomes orientation to quality measurement, and evaluating quality assurance activities. Largely on the basis of the thrust of these new directions, the committee made ten major recommendations. Two recommendations proposed expanding the statutory mission of the Medicare program to include responsibility for quality of care for the elderly, with quality of care defined as "the 1   Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990.

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Medicare: New Directions in Quality Assurance degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." A third recommendation focused on the needs for research in areas of clinical evaluation (e.g., quality of care, outcomes, and effectiveness), and a fourth called for expanded training for health professionals in quality assurance and research. A fifth recommendation called for reorganizing the current PRO program into a Medicare Program to Assure Quality; two related recommendations addressed implementation of that new effort. Finally, three recommendations concerned public oversight, accountability, and evaluation of the new program. An expanded mission for Medicare would aim to improve the quality of health care for Medicare enrollees, strengthen the ability of health care organizations and practitioners to assess and improve their own performance, and identify and overcome system and policy barriers to achieving good quality of care. A comprehensive system of quality assurance for Medicare would aim to develop tools to help providers improve the health of the elderly and to monitor their own performance, improve communication between clinicians and patients, broaden the concerns for the health and well-being of the elderly, and serve as a prototype for quality assurance systems for other parts of society. THE INSTITUTE OF MEDICINE CONFERENCE ON MEDICARE: NEW DIRECTIONS IN QUALITY ASSURANCE The committee considered its final report only one important product of the study. Promoting discussion and provoking reactions from the intended audiences were equally important. With this in mind, an invitational conference was convened in May 1990 to give interested parties an opportunity to discuss the key themes of the report, address special implementation issues, examine research and training agendas, and comment on specific actions that might be undertaken in the public and private sectors in response to the report's recommendations. The remainder of this monograph comprises the papers, presentations, and discussions at the conference. THE CONFERENCE AGENDA Rather than focusing the conference on the specific recommendations of the committee, the program agenda emphasized the underlying principles that can provide "new directions" in quality assurance, as noted above. Thus, parts of the conference addressed the following themes: "More Professionalism, Less Regulation"; "Organization- and System-Focused Quality Improvement"; ''Improved Decisionmaking by Patients and Clinicians"; "A Patient Outcomes Orientation''; and "Public Accountability and Program

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Medicare: New Directions in Quality Assurance Evaluation." Each part was introduced by an IOM study committee member and included one major presentation by a committee member and a response by a ranking expert who had not been a member of the committee. Two panels discussed implementation of study recommendations. The first panel examined special issues in understanding the epidemiology of quality problems, responding to legal concerns, and translating the IOM report strategy beyond the Medicare program. The second panel addressed the research, training, and capacity building agendas called for in the study report. In addition, "responses" to the report were heard from a diverse set of interested parties, including two members of the U.S. Congress and several national leaders in the health care professions. We were fortunate in the insightful and thoughtful comments given by both the speakers and the participants at the conference. With this proceedings we invite our readers to join the discussion.