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Medicare: New Directions in Quality Assurance
MEDICARE
New Directions in Quality Assurance
Proceedings of an Invitational Conference by the INSTITUTE OF MEDICINE
Division of Health Care Services
Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr, editors
NATIONAL ACADEMY PRESS
Washington D. C.
1991
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Medicare: New Directions in Quality Assurance
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competencies and with regard for appropriate balance.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education.
This conference was supported by the Health Care Financing Administration, U.S. Department of Health and Human Services, under Cooperative Agreement No. 17-C-99170/3.
Library of Congress Catalog Card No. 90-63821
International Standard Book Number 0-309-04429-4
Additional copies of this report are available from:
National Academy Press
2101 Constitution Avenue, NW Washington, DC 20418
S274
Printed in the United States of America
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Medicare: New Directions in Quality Assurance
COMMITTEE TO DESIGN A STRATEGY FOR QUALITY REVIEW AND ASSURANCE IN MEDICARE
STEVEN A. SCHROEDER, Chair, Chief,
Division of General Internal Medicine, University of California, San Francisco, California
MARK R. CHASSIN,
Value Health Sciences, Santa Monica, California
LEO M. COONEY, Jr.,
Yale University School of Medicine and Yale-New Haven Hospital, New Haven, Connecticut
ROBERT B. COPELAND,
Georgia Heart Clinic, LaGrange, Georgia
CHARLES J. FAHEY,
Third Age Center, Fordham University, New York, New York
PAUL F. GRINER,
University of Rochester Medical Center and Strong Memorial Hospital, Rochester, New York
WILLIAM S. HOFFMAN,
Social Security Department, International Union, United Auto Workers, Detroit, Michigan
ROBERT L. KANE,
School of Public Health, University of Minnesota, Minneapolis, Minnesota
HAROLD S. LUFT,
Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California
MAXWELL J. MEHLMAN,
The Law-Medicine Center, Case Western Reserve University School of Law, Cleveland, Ohio
MARIE MICHNICH,
American College of Cardiology, Bethesda, Maryland
MARILYN MOON,
Public Policy Institute, American Association of Retired Persons, Washington, D.C.
JAMES D. MORTIMER,
Midwest Business Group on Health, Chicago, Illinois
ALBERT G. MULLEY, Jr.,
General Internal Medicine Unit, Massachusetts General Hospital, Boston, Massachusetts
EDWARD B. PERRIN,
Department of Health Services, University of Washington, Seattle, Washington
MARGARET D. SOVIE,
Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
LORING W. WOOD, NYNEX
Corporation, White Plains, New York
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Medicare: New Directions in Quality Assurance
STUDY STAFF
Division of Health Care Services
KARL D. YORDY, Director
KATHLEEN N. LOHR, Study Director
MOLLA S. DONALDSON, Associate Study Director
JO HARRIS-WEHLING, Staff Officer
ALLISON J. WALKER, Research Associate
H. DONALD TILLER, Administrative Assistant
THELMA COX, Senior Secretary
THERESA NALLY, Senior Secretary
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Medicare: New Directions in Quality Assurance
Acknowledgments
The contributions of several members of the Institute of Medicine staff deserve special mention. Theresa Nally, Senior Secretary for the project, both assisted with the conference and prepared the manuscript. Thelma Cox, Project Secretary, H. Donald Tiller, Administrative Assistant, Allison J. Walker, Research Associate on the study, and Wallace K. Waterfall, Director of the Office of Communications, also provided valuable assistance. The consistent and generous support of Karl D. Yordy, Director of the Division of Health Care Services, deserves special mention.
Support for the study was provided by the U.S. Department of Health and Human Services, Health Care Financing Administration. We acknowledge the assistance of the government's project officer, Harry L. Savitt of the Office of Research and Demonstrations. The Institute of Medicine provided partial support for this monograph through its discretionary funds.
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Medicare: New Directions in Quality Assurance
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Medicare: New Directions in Quality Assurance
Contents
ACKNOWLEDGMENTS
v
PART I:
INTRODUCTION
1.
Introduction
Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr
3
2.
The Institute of Medicine Report
Steven A. Schroeder
7
PART II:
NEW DIRECTIONS: MORE PROFESSIONALISM, LESS REGULATIONS
William S. Hoffman
17
3.
The Committee View
Leo M. Cooney, Jr.
18
4.
A Response
Lonnie R. Bristow
22
PART III:
NEW DIRECTIONS: ORGANIZATION- AND SYSTEM- FOCUSED QUALITY IMPROVEMENT
Loring W. Wood
29
5.
The Committee View
James D. Mortimer
31
6.
A Response
Chip Caldwell
37
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Medicare: New Directions in Quality Assurance
PART IV:
NEW DIRECTIONS: IMPROVED DECISIONMAKING BY PATIENTS AND CLINICIANS
Robert B. Copeland
47
7.
The Committee View
Paul F. Griner
48
8.
A Response
John Rother
54
PART V:
NEW DIRECTIONS: A PATIENT OUTCOMES ORIENTATION
Charles J. Fahey
61
9.
The Committee View
Albert G. Mulley, Jr.
63
10.
A Response
John E. Wennberg
73
PART VI:
NEW DIRECTIONS: PUBLIC ACCOUNTABILITY AND PROGRAM EVALUATION
Marilyn Moon
81
11.
The Committee View
Maxwell J. Mehlman
82
12.
A Response
Duncan vB. Neuhauser
86
PART VII:
CONFRONTING SPECIAL IMPLEMENTATION ISSUES
Mark R. Chassin
93
13.
The Epidemiology of Quality Problems
R. Heather Palmer
96
14.
Legal Concerns
Alice G. Gosfield
105
15.
Translating the Institute of Medicine Report Strategy Beyond Medicare
James S. Roberts
116
Part VIII:
NEW DIRECTIONS: THE RESEARCH, TRAINING, AND CAPACITY, BUILDING AGENDAS
Edward B. Perrin
129
16.
Research and Capacity Building: Issues Raised by the Institute of Medicine Report
Harold S. Luft
130
17.
The Research Agenda: An Outside View
Sheldon Greenfield
140
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Medicare: New Directions in Quality Assurance
18.
The Training and Capacity Building Agendas: An Outside View
Edward W. Hook
145
PART IX:
RESPONSES TO THE INSTITUTE OF MEDICINE REPORT RECOMMENDATIONS
Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr
153
19.
A Legislator's Response to the Institute of Medicine Report
David F. Durenberger
155
20.
A Legislator's Response to the Institute of Medicine Report
J. Roy Rowland
161
21.
A Physician's Response to the Institute of Medicine Report
Arnold S. Relman
167
22.
An Administration Response to the Institute of Medicine Report From the Agency for Health Care Policy and Research
Linda K. Demlo
174
23.
An Administration Response to the Institute of Medicine Report From the Health Care Financing Administration
Thomas G. Morford
179
24.
A Peer Review Organization Response to the Institute of Medicine Report
William H. Moncrief, Jr.
186
PART X:
WHERE DO WE GO FROM HERE?
Molla S. Donaldson, Jo Harris-Wehling, and Kathleen N. Lohr
193
25.
Where Do We Go From Here?
Ceylon S. Lewis, Jr.
194
26.
Where Do We Go From Here?
Jerome H. Grossman
198
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Medicare: New Directions in Quality Assurance
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