Steven A. Schroeder
Welcome. We have a lot to do today. We are here to see whether this report (IOM, 1990) will sink like a stone, as some Institute of Medicine (IOM) studies do, or whether it will stimulate some reaction. The committee worked very hard on this project throughout the past two and a half years, and 15 of the 17 members of the committee are participating in this conference. To assess whether we should go further with this effort, we are going to need your reactions and comments, both to the IOM report itself and on what the next directions should be. To begin this process, I will summarize very briefly some of the highlights of this two-volume report.
We were asked by Congress to do a number of things:
define quality of care,
describe current methods to measure, review, and assure quality,
evaluate the adequacy of current methods for preventing, detecting and correcting problems of poor quality,
set up a research agenda,
consider how coordination and supervision of quality at the national level should be done, and
look at criteria for allocation of funds and personnel.
To do this, the IOM put together a very interesting committee. Included on it were people from the research community, biostatistics, geriatrics, private practice of medicine, social work, nursing, hospital administration,
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Medicare: New Directions in Quality Assurance 2 The Institute of Medicine Report Steven A. Schroeder Welcome. We have a lot to do today. We are here to see whether this report (IOM, 1990) will sink like a stone, as some Institute of Medicine (IOM) studies do, or whether it will stimulate some reaction. The committee worked very hard on this project throughout the past two and a half years, and 15 of the 17 members of the committee are participating in this conference. To assess whether we should go further with this effort, we are going to need your reactions and comments, both to the IOM report itself and on what the next directions should be. To begin this process, I will summarize very briefly some of the highlights of this two-volume report. CHARGES TO THE COMMITTEE We were asked by Congress to do a number of things: define quality of care, evaluate standards, describe current methods to measure, review, and assure quality, evaluate the adequacy of current methods for preventing, detecting and correcting problems of poor quality, set up a research agenda, consider how coordination and supervision of quality at the national level should be done, and look at criteria for allocation of funds and personnel. To do this, the IOM put together a very interesting committee. Included on it were people from the research community, biostatistics, geriatrics, private practice of medicine, social work, nursing, hospital administration,
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Medicare: New Directions in Quality Assurance American Association of Retired Persons, labor, business and industry, health economics, law, and the Washington inside scene. The focus of the study was deliberately broad. We looked at the beneficiaries. We looked at different settings of care. We excluded nursing homes in view of the fact that the IOM had just released a very comprehensive study on care in nursing homes. We looked at ambulatory care, both fee for service and in health maintenance organizations (HMOs). We said, "Let's take a long-term view and admit that under current conditions, we do not know what the financial or organizational structures are going to look like by the year 2000. Many things might happen, so let's have a strategy that is broad enough and flexible enough to respond to different and perhaps unforeseen developments." DEFINING QUALITY OF CARE The first thing we did—and it took us a long time—was to come up with a definition: "Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." Let me walk through that definition a bit because it is important to understand its full interpretation. First, the concept that quality is a probabilistic, not a dichotomous, concept is very critical. Second, we are talking about all people eligible for Medicare, not just those who check into a hospital and have something done to them. This is a very important criterion in examining what the data base should be for looking at quality. Third, desired health outcomes involve patient preferences. Fourth, health services must be consistent with current knowledge. Fifth, these latter two points imply that the medical care system and its practitioners are involved in a dynamic structure. We thought that this was a broader and a more compatible definition of quality than others that we could have chosen. FINDINGS Health Care and Health of the Elderly What did we find? Regarding the elderly themselves, there were no big surprises. There are going to be more elderly, and they will constitute a larger proportion of the population. The good news is that people are living longer. Compared with most other Western countries, we may not do very well as regards the infant mortality rate, but we do pretty well once we hit age 65. Although it is not true for a U.S. infant, a 65-year-old in the United
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Medicare: New Directions in Quality Assurance States does relatively well in comparison with his or her German or French counterpart. An increasing number of elderly will be living with chronic illness and disabling conditions. As regards Medicare and the elderly, the elderly have better access to health care than any other age group. Still, health care costs continue to rise, and pressures for cost containment continue to increase. Much health care has shifted out of the hospital into outpatient settings, long-term-care facilities, and the home. Gaps in coverage and financial barriers are going to pose increasing problems in terms of quality and access. Burden of Harm To devise a program that looks at a problem, we have to know the nature of that problem. We spent quite a bit of time trying to see if we could quantify the burden of poor quality. The data here are surprisingly spotty. The types of quality problems include poor technical quality, overuse, and underuse. We found that there is a lot of poor performance. From testimony we heard, it is spread throughout the population but is also concentrated in outliers. We know a moderate amount about technical problems, but we do not know as much about deficient interpersonal skills, although we suspect that this, too, is a major quality issue. Overuse is probably the best documented of the three quality areas. We know that a substantial amount of overuse exists in surgery, prescription drugs, and invasive diagnostic technologies, and because each instance of overuse carries a finite risk of patient harm, every unnecessary operation or drug or invasive diagnostic procedure is a quality problem. As regards underuse, the literature is just not that robust. We think there is a lot of underuse, but it is harder to measure. It does pose risks to patients. The committee concluded that the burden of poor quality included all three of these categories. We cannot put a percentage on them, but we think it is very important that quality-of-care systems focus on all of them, not just on one, and we are afraid that much of the current scrutiny on quality of care focuses only on poor technical performance. Approaches to Quality Assurance What have been the approaches to quality assurance? In terms of concepts, we do not think there is a single approach that will apply to every setting and each type of quality problem. So, the classic triad of structure, process, and outcome still makes a lot of sense. We heard a lot about the continuous improvement approach, and it was striking how conceptually appealing this approach is.
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Medicare: New Directions in Quality Assurance The practical state of development of this new approach, however, reminds me of a story in David Halberstam's The Best and the Brightest (1972). When Lyndon Johnson emerged from his first Kennedy cabinet meeting, he remarked to Sam Rayburn how awed he was by the intelligence of the assemblage: "Sam, these people are so bright I can't believe it." Rayburn listened for a time and then replied, "Well, Lyndon, that's all very good. I'd just feel better if one of them had ever run for sheriff." We found that there is a tremendous amount of intellectual excitement and energy about the continuous improvement model, but it has yet to run for sheriff. So we are going to wait and see what happens when that model is applied in the field; if it is half as good as its proponents say it is, then we are in for an exciting time. However, we did not think, as a responsible committee, that the evidence was sufficiently good for us to declare it a definitive solution. We concluded that different approaches were needed for different sites of care (e.g., hospital, home and ambulatory setting). Because incentives differ depending on how care is paid for and organized, we may need to be flexible and have different safeguards depending on whether patients are in HMOs or in fee-for-service settings. Current quality assurance methods tend to focus on single events and single settings. They concentrate on what happens during hospitalization, rather than episodes of care or continuity of care. They are particularly deficient in diagnosing underuse or overuse of health services. If unnecessary bypass surgery is done with technical proficiency, that usually does not show up as a quality problem, particularly given the ambiguity in indications for bypass surgery. Outliers account for a large proportion of the serious quality problems identified by the current methods. We heard some impressive testimony from two different states that a large proportion of the quality problems was traced to a relatively small cohort of practitioners and their hospitals. We heard, on the other hand, that once those problems were looked at, not much could be done to rectify them. As a system, our capacity to identify problems is much more advanced than our capability of remedying those problems. The current system of quality assurance does little to improve the behavior of the average provider. Peer Review Organizations What about the function of the Medicare Peer Review Organizations (PROs), which are the statewide organizations that conduct review in the Utilization and Quality Control Organization Review program administered by the Health Care Financing Administration? We had an opportunity to visit many of them and talk with many of their representatives. We ac-
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Medicare: New Directions in Quality Assurance knowledge the value of the infrastructure of the PROs, but we also concluded that some criticism is merited and that the PRO focus remains on utilization and cost more than quality. This reflects the language of the PRO legislation and the approach to funding PROs. The PRO focus in terms of quality is on outliers, rather than on the average provider, and they were almost totally concerned with hospital care. The committee found that PROs were felt to pose an excessive burden on providers. It is our impression that a perception of bureaucratic harassment of practicing physicians—especially those in primary patient care—has served to diminish the attractiveness of the profession, and there was a sense that the PROs were part of the problem. Rather than having a two-tailed approach—to reward the virtuous and to try to correct those who are not—the PROs only looked at one tail of the behavioral spectrum, resulting in an adversarial and punitive process that did not work very well. The kinds of funding arrangements that the PROs were working under were quite rigid. There was a lot of redundancy with other programs, particularly in the private sector. Finally, and perhaps most critically, there was no public oversight of the program to see whether it did what it was supposed to do, if it were possible to judge what it was supposed to do. So we felt that the opportunity was there to make explicit the goals and the directions of quality assurance. Capacity Building We were also asked to set forth our recommendations for a national quality assurance structure. We said that at the present time, we were not sure that the nation has the capacity for a comprehensive and effective quality assurance system. We need to know more about the basic methods of detecting, and particularly of correcting, quality assurance problems. To do that, we needed to expand capacity in terms of generating the people with the requisite skills who are needed for the task. We also felt that it would be important to share national outcomes data with patients and health care workers so that patients could select the type of medical care they felt was most congruent with their desired outcomes. A STRATEGY FOR MEDICARE QUALITY ASSURANCE We think a shift in emphasis needs to take place—from individual providers and events of care to episodes of care. The focus needs to be broadened from the hospital to all settings, particularly given the way that changes in economics and technology have altered the site of delivery of medical care. We need to have much more public oversight and evaluation of what we are doing and how we are doing it.
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Medicare: New Directions in Quality Assurance The current emphasis on regulation, inspection, and monitoring needs to focus as much as possible on the virtuous aspects of professionalism. A quality-of-care approach should appeal to the best side of health professionals to help them to carry out the mission that inspired them to enter health care. We should strive for improvement rather than inspection, turning the task as much as possible internally to let groups improve themselves. We should shift the focus more from just looking at the provider to examining patient interactions with providers. We should give the data collected in quality assurance efforts back to people working in the health care field so that they can make more informed decisions about what they are doing now and how they can do better in the future. Mission and Goals of Medicare Program We thought it was very important to expand the mission of Medicare, to make explicit the responsibility of assuring the quality of health care for enrollees in Medicare. A virtue of our definition is that it looks at populations. For example, if 20 percent of the elderly population never get any health care and die or suffer adverse functional outcomes, this problem would not be detected by the PRO program, because it only measures what happens to people who enter the health care system. Three explicit goals for the quality assurance system should be articulated: to improve continuously the quality of health care for enrollees; to strengthen the ability of health care organizations and practitioners to assess and improve their own performance; and to identify barriers to achieving quality of care and then see how we can overcome those barriers. Medicare Program to Assure Quality To achieve these goals, we recommended restructuring the PRO program. We proposed renaming it the Medicare Program to Assure Quality (MPAQ). Its functions should be defined, and Medicare Conditions of Participation for hospitals should be consistent with these functions. Let me give you the committee's rationale for thinking there needed to be a Quality Program Advisory Commission (QualPAC). One of the problems facing the way health care is looked at in this country is that it is divided up into neat little boxes, but the linkages across different territories are not done very well. So many aspects of health care affect the elderly that there needs to be an oversight group with the breadth, vision, and political independence to analyze data from every possible source and to say, in a nonpartisan, nonbureaucratic, nonterritorial way, "Here are the kinds of problems we should address." We were probably influenced by the two commissions that Congress has set forth, the Prospective Payment Assessment
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Medicare: New Directions in Quality Assurance Commission (PROPAC) and the Physician Payment Review Commission (PPRC), which have their own major assignments. This quality advisory commission ought to oversee the activities of the Medicare quality program and report periodically to Congress on how MPAQ is doing. We also thought there should be a National Council, established within the Department of Health and Human Services (DHHS), to assist in implementation, operation, and evaluation of the MPAQ and to tackle difficult policy issues, for example, the release of quality data on individual hospitals or other providers. This is the kind of group that could take a look at that and say, "Yes, we think that the data are sufficiently strong to be released," or "No, let's reanalyze the data." We recommend that the Secretary report to Congress on quality of care for Medicare beneficiaries and on the effectiveness of the Medicare Quality Assurance Program—how well it is doing in meeting those three goals I mentioned earlier—at least every two years. The Health Care Financing Administration (HCFA) will have responsibility for the MPAQ and for the local organizations, the Medicare Quality Review Organization (MQROs), to carry out those functions with the assistance of contractors, if the organization needs them. The Department of Health and Human Services will have its National Council as well as outside technical advisory personnel, and Congress will have an Advisory Committee to take the broadest possible look. More specifically, HCFA's responsibilities for the MPAQ are to set up both a short- and a long-term program. We are talking about a ten-year period to get the data that are required to do some of the outcome feedback we have talked about. There should be monitoring and evaluation of the local operations. HCFA will also collect, analyze, and use the feedback process and outcome data to inform internal quality assurance programs. All this may be done by MQROs in some instances, or certain groups may decide to do much of the data collection and analysis on their own, but all providers groups, facilities, and the like will be assisted by feedback of pertinent data. Information will be reported back to the larger program in order to consider rewards, interventions and even sanctions if they seem necessary. DHHS will have its National Council to advise on how this program is performing, what mid-course corrections need to be made, and what the next steps are. It will be assisted by a Technical Advisory Panel, again to enhance public oversight and evaluation. Finally, responsibilities of the Congress will be to establish QualPAC, which will advise Congress on quality assurance and report on quality of care for the elderly. One of the responsibilities of the Congress will be to assure adequate funding for this program so that it can achieve the desired level of performance.
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Medicare: New Directions in Quality Assurance Finally, we need to improve the capacity of the system in terms of its research and knowledge base, and the kinds of personnel that will staff it. REFERENCES Halberstam, D. The Best and The Brightest. New York, N.Y.: Random House, 1972. Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990.