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PART VII
Confronting Special Implementation Issues



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Medicare: New Directions in Quality Assurance PART VII Confronting Special Implementation Issues

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Medicare: New Directions in Quality Assurance This page in the original is blank.

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Medicare: New Directions in Quality Assurance Confronting Special Implementation Issues: Introduction Mark R. Chassin This part of the conference proceedings addresses three issues that our report deals with only indirectly (IOM, 1990): the epidemiology of quality problems, legal concerns, and the relationship of Medicare's quality efforts to those of other sections of the health care system. They are taken up, respectively, by R. Heather Palmer, a pediatrician by training who is now a Lecturer at the Harvard School of Public Health and Director of the Center for Quality of Care Research and Education; Alice G. Gosfield, a practicing attorney in Philadelphia with long experience in medicolegal issues, particularly those pertaining to peer review; and James S. Roberts, a physician with many years of work in the quality-of-care field and currently Senior Vice President of the Joint Commission on Accreditation of Healthcare Organizations. These issues form a major part of the environment in which the Medicare quality assurance strategy that we have laid out in such detail must be implemented and played out. We considered each of the three areas, but—unlike topics covered in the earlier presentations—we did not make specific recommendations that pertained directly to them. Rather, we clearly identified them as very important components of the system either as constraints, as obstacles, or simply as facts that quality assurance has to take into account. The remainder of this brief introduction gives the context in which the committee saw these issues and then raises some of the questions each of them poses. I doubt we are going to have very many answers, but we do need to ask the questions. On the epidemiology of quality problems it was clear to us early on that in trying to set a strategy for quality assurance it would be nice to know what quality problems existed out there and, in fact, what the burden of harm of these quality problems was. Particularly in considering just the major categories that we identified—overuse, underuse, and misuse or

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Medicare: New Directions in Quality Assurance improper use—it is quite critical to the rational allocation of quality assurance resources to know something about the relative distribution of those problems. Each of them requires very different measurement techniques. If, for instance, you are measuring underuse, you have to look at populations. If you are measuring overuse, you have look at specific incidents of care. They also require very different means of intervention and different monitoring mechanisms. To even begin to set up a quality assurance strategy—a real quality assurance program—one would like to know what the distribution of those problems is and, even more specifically, within each of those domains what are the most common, what are the most difficult, what are the most burdensome problems? Well, we learned very early that very little is known about that distribution. The question is how do we proceed in the absence of such data? Clearly, it is not responsible to say we have to wait until the research findings roll in over the next 20 years, if in fact they will, because we will always have incomplete information. So the problem that Medicare faces, indeed that all quality assurance programs face, is how to proceed in the absence of those kinds of data. Second, legal concerns form a major part of the environment. Those concerns arise in a number of different domains. As the committee gathered its data, certainly we heard a lot from Medicare Peer Review Organizations (PROs), from state health departments, and from state licensing boards about how difficult it is, even after identifying a ''bad apple,'' to sanction that aberrant provider unless he or she is a drug addict or sell drugs as a physician. I read the California licensing board's deliberations every month, and they are virtually all (certainly 90 percent of them) about acts of sexual deviance or acts of drug addiction or drug selling. Very few instances of quality of care become the basis for licensing board sanctions. Why is it that sanctioning providers is so extraordinarily difficult? was the recurrent theme. Is it a process problem? Is it simply an obstacle in the environment that will never be made any easier? What can we learn about how that process can be improved? What about malpractice concerns? Can we get physicians to give up defensive medicine? This constitutes some finite fraction of overuse although we know very little about exactly what proportion it constitutes. Can we really expect physicians to give that up unless the tort system is completely dismantled and completely reformed, as Relman (1991) suggests? Relman also mentions antitrust as another force in the environment that makes physicians very reluctant to undertake, at the local level, at the hospital staff level, or even at the organizational level, sanctions against providers who may be misbehaving. Other presentations note that the report calls for a massive amount of new information about outcomes that are physician specific and that are

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Medicare: New Directions in Quality Assurance hospital specific. How are these sensitive data going to be handled? What about confidentiality? How are they going to be released? To whom? Under what circumstances? Last on our list of "simple problems" is, How does the Medicare strategy relate to everything else that is out in the environment—to the other players in quality assurance? Another repetitive theme the committee heard was that providers are excessively burdened by the multiple agencies involved in quality assurance independently demanding the same information in an uncoordinated fashion. So the final issue of this set of three special topics concerns how the Medicare strategy fits into what everybody else is doing. REFERENCES Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990. Relman, R.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.