Improving the Infrastructure for Effective Change

Making policy is not the same as implementing it. The necessary conditions for effective short-and long-term implementation of a proposal for health care reform should be considered in the design of the proposal. Some of the conditions for successful change involve matters beyond the scope of a reform proposal per se, for example, political leadership and the general condition of the economy. Reform proposals should, however, discuss how certain broad features of the governmental and health care delivery infrastructure will be designed or shaped to support the objectives of reform. Four important elements of this infrastructure are:

  • governance and administration, which involve the transformation of statutes into regulations, enforcement and oversight mechanisms, and other public and private actions needed to implement reforms;

  • human and physical capital, which includes the appropriate level, mix, and distribution of health care professionals, facilities, and equipment;

  • knowledge development, that is, the biomedical, clinical, and health services research and the health data systems that create, aggregate, analyze, and disseminate information that practitioners, administrators, consumers, and others need to continuously improve health and meet other objectives of reform; and



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Assessing Health Care Reform Improving the Infrastructure for Effective Change Making policy is not the same as implementing it. The necessary conditions for effective short-and long-term implementation of a proposal for health care reform should be considered in the design of the proposal. Some of the conditions for successful change involve matters beyond the scope of a reform proposal per se, for example, political leadership and the general condition of the economy. Reform proposals should, however, discuss how certain broad features of the governmental and health care delivery infrastructure will be designed or shaped to support the objectives of reform. Four important elements of this infrastructure are: governance and administration, which involve the transformation of statutes into regulations, enforcement and oversight mechanisms, and other public and private actions needed to implement reforms; human and physical capital, which includes the appropriate level, mix, and distribution of health care professionals, facilities, and equipment; knowledge development, that is, the biomedical, clinical, and health services research and the health data systems that create, aggregate, analyze, and disseminate information that practitioners, administrators, consumers, and others need to continuously improve health and meet other objectives of reform; and

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Assessing Health Care Reform public health policies and programs that focus on the community rather than on the personal health services that are the central concern of health care reform. In addition, other elements may be considered part of the administrative apparatus necessary to promote the goals of health care reform in the longer run or to advance other important social goals. Among these are, for example, the definition of clinical malpractice, the creation of better legal responses to clinical errors, and the protection of the privacy and confidentiality of sensitive patient data that reside in computer-based records and databases. GOVERNANCE AND ADMINISTRATION Different reform proposals involve vastly different and difficult-to-catalog levels and distributions of governance and administrative responsibilities. The committee does not take a position on the "ideal" administrative structure for health care reform; that structure must be fitted to the specifics of a particular proposal. Whatever the specific, however, reform proposals should be clear about the roles, responsibilities, accountabilities, and interrelationships of the public and private sectors in implementing the proposal and achieving its objectives. Proposals should define explicitly: the program management responsibilities that will reside in the public sector and the level of government—federal, state, local, or some combination—that should discharge them; the administrative tasks to be undertaken by private sector entities such as employers, fiscal intermediaries, or health care providers; and the role, if any, of quasi-public organizations such as a commission or board that might define covered services or certify health plans for which public enrollment subsidies would be available. Most reform proposals will probably require some reorganization of the Department of Health and Human Services to accommodate new responsibilities and realign existing activities. The nature of this

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Assessing Health Care Reform reorganization will necessarily differ for different plans, and many details may properly be worked out subsequent to the adoption of reform legislation. Nonetheless, the basic assignment of planning, operational, oversight, and evaluative tasks needs some preliminary definition. As one example, a federal role in quality monitoring and improvement may call for the creation of a new entity or agency that can address quality of care problems and promote quality improvement activities for the entire age range covered by the health plans (i.e., not just the elderly covered by the Medicare program's Peer Review Organization effort). All reform proposals should provide for greater standardization and efficiency in some administrative tasks. This should be simpler for some proposals, for example, those that call for automatic enrollment (e.g., at birth) in a single national health plan. Proposals that incorporate competitive health plans will have to identify how much uniformity and simplicity is desirable and feasible with respect to such matters as criteria or rules for monitoring the quality and appropriateness of services, tracking eligibility for coverage under different health plans, filing claims for payment, reporting information on outcomes, and using electronic data interchange technologies. The Workgroup for Electronic Data Interchange (1992) has recommended that such computerized capabilities be adopted by all insurers, employers, and providers. The IOM has urged reductions in the intrusive and disruptive micromanagement of clinical practice that now prevails through many utilization management programs (IOM, 1989b). The committee endorses the principles and aims of these earlier groups. Although some short-term costs will likely be incurred in achieving greater uniformity, simplicity, and efficiency in program administration, costs should be reduced over time. Frustration with the system should also decrease among most affected parties—patients, clinicians, and administrators. The criterion for judging the appropriateness of whatever administrative tasks—and thus costs—remain is the degree to which they serve desired objectives related to access, quality, equity, efficiency, and information. The bases for evaluating claims in these areas are not obvious or agreed upon by experts, but the committee believes that reform proposals ought to have some clear and defensible statements about expectations concerning administrative costs and savings.

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Assessing Health Care Reform Beyond these statements, the administrative implications of different reform proposals and the need for program specifications vary so much that only examples will be given of the kinds of administrative issues that should be covered in reform proposals. For instance, reform proposals that envision negotiations between physicians and payers over payment for medical services probably will require adjustments in antitrust policies, as well as guidelines and rules for the negotiation process and its outcomes, and should specify who would make decisions if negotiations fail. To cite another example, some reform proposals may call for certain services to be provided through regional institutions such as designated transplantation centers, shock-trauma units, and neonatal and pediatric intensive care units. Proposals for such regionalization should be as specific as possible about what services might be regionalized (if that is known) or what criteria and processes would be used to identify such services, as well as about how such institutions will be identified, certified or designated, and recertified. Some delegation of decisionmaking to the states might, for example, be explicitly anticipated. Virtually no observers of the health care scene believe that reform can be or will be instantaneous. Rather, many elements of reform will have to be phased in, and some steps may have to be contingent on the outcomes of earlier changes. The committee recommends that reform proposals be clear and realistic about the timetable expected for full implementation. Moreover, monitoring mechanisms will be needed to detect inadequate implementation, unanticipated negative effects, and positive results that should be built upon. The full details of the timetable for implementation may emerge as the initial stages of the implementation move forward, but the reform plan should reflect careful consideration of the phasing of implementation—those aspects that are essential first steps and those that will require the development of new tools and programs. The monitoring and evaluation efforts will be essential elements of the phasing, and clear responsibilities for such long-term monitoring and research should be described. Ongoing program evaluation, although expensive and time consuming, provides the knowledge to determine whether we are moving in the directions sought through health care reform and to make appropriate mid-course corrections in policies or their implementation.

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Assessing Health Care Reform HUMAN AND PHYSICAL CAPITAL In extending health insurance coverage and pursuing serious cost containment, health care reform, regardless of its form, will shape the demand for and distribution of human and physical capital. This shaping may be unintended (as, for example, was the impact of initial Medicare reimbursement policies on hospital capital financing and on the relative incomes of physicians by specialty). Alternatively, the reform plan can include deliberate steps to ensure that human and physical capital support reform goals. A variety of mechanisms currently direct the flow of capital resources: market forces heavily influenced by reimbursement policies of payers in the public and private sectors, public and private regulations, and specific investment policies. Many actors—public and private—have determined these policies. Another characteristic of decisions about capital is their long-term impact. The training of a physician takes many years; a hospital facility will last decades. Thus, steps taken today can be expected to have effects a quarter-century from now. Because a health care reform plan is unlikely to replace totally this configuration of factors affecting capital, the committee believes that it is critical for the reform plan to give explicit attention to both health personnel and physical capital policies that connect these important long-term inputs to the desired objectives of the reform plan. This attention should deal with at least the following: reimbursement policies that shape the market forces driving many human resource and physical capital decisions made by individuals and institutions; policies that provide direct investment in capital, such as support of health professions education and public sector support for capital plants and equipment; policies for the distribution of highly specialized, capital-intensive services for which distribution by market forces alone may not be desirable; regulatory policies that affect the supply, distribution, and roles of health personnel; and

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Assessing Health Care Reform policies that affect the development and introduction into practice of new technologies and procedures that will help form the human and physical capital requirements of the future. Without taking a stand on the nature of the policies, the committee recommends that any plan should make clear how it will deal with issues of human and physical capital supply and distribution. The plan need not specify detailed approaches to all of these issues. It should indicate, at least, a process by which policies will be established and effects of the reform plan on capital will be monitored so that policies can evolve in support of the plan's goals. The reform plan's objectives must be congruent with the long-term development of health personnel and physical capital. The plan should consider the establishment of an ongoing commission, or other equivalent mechanisms, that can ensure this congruence of policies as the plan evolves, monitor results, and make the necessary mid-course corrections. The committee also notes that health care reform plans calling for major reconfigurations of arrangements for services, such as the creation of new health care plans providing comprehensive services, will generate up-front capital requirements to pay for the costs of the necessary consolidations and reorganizations of providers. These initial investments in organizational capital will need to be financed out of the future stream of revenue. Human Capital Several prominent proposals for health care reform emphasize primary care providers and their role as the managers, coordinators, or gatekeepers of health care services for patients. This stance presupposes an adequate supply of primary care physicians and other practitioners, such as nurse practitioners and physician assistants. This assumed supply does not match either today's mix of specialists and generalists or the mix projected to emerge in the next several years from today's professional training programs. In the short run, therefore, such reform proposals must be clear as to how the proposed system will actually function, given the current supply of primary care physicians.

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Assessing Health Care Reform ("Current" in this context implies through roughly the year 2010.) In the longer run, attention will need to be directed at determining "what the right numbers are" for generalists and specialists and how the relevant education and training programs will be supported. The committee recommends that health care reform proposals describe policies and priorities that determine the role of various providers, including nurses and physicians, and the settings from which they should deliver care. Particular emphasis must be given to primary care providers and how the shortfall in such clinical disciplines can be overcome both in the near term and over the longer run through changes in practitioner payment methods, educational programs, and improvements in the attractiveness of the primary care function. Significant changes in the pattern of financing may leave certain types of health professions education and training vulnerable to underfunding, possibly graduate medical and nursing education in particular. Conversely, reform also creates opportunities for effecting desired changes in health professions education (as implied above concerning primary care), and these opportunities should be identified and seized even in the early years of reform. A number of IOM reports have dealt with the need to strengthen primary care (1978, 1984a,b), nursing and nursing education (1983), future directions for the allied health professions (1989a), and support of graduate medical education in ambulatory settings (1989d). Most of these reports discuss the important correlation between the methods and patterns of health care financing and the training and deployment of health personnel. Those designing health reform packages should take account of these well-known relationships in contemplating how the reimbursement of plans, networks, purchasing cooperatives, facilities, and free-standing practitioners (e.g., physicians or nurse practitioners) might be managed to achieve more appropriate incentives for the cost-effective deployment of human resources and supportive educational and retraining strategies. Since much of the support for the education and training of health personnel is derived from the financing of patient care, changes in the patterns of that financing will need to give specific attention to adequate financing of educational programs appropriate for the reform strategy. The financing can be included in or separated from

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Assessing Health Care Reform the financing of patient care. Since much of the support for the education and training of health personnel is derived from the financing of patient care, changes in the patterns of that financing will need to give specific attention to adequate financing of educational programs appropriate for the reform strategy. The financing can be included in or separated from the financing of patient care. Physical Capital Through the years, the United States has wavered between varied, and sometimes conflicting, policies concerning the supply and distribution of physical capital. Direct public investment (e.g., the Hill-Burton program), state and regional planning (voluntary or enforced through certificate of need), and market forces responding to reimbursement policies have all been used. A health care reform plan should be explicit about how it will influence investment in physical plants and equipment to be consistent with the fundamental goals of access, efficiency, and quality. The plan will need to be concerned, at the least, with the geographic distribution of services (including regionalization of highly specialized services), reduction of unneeded capacity or redistribution of existing capacity, response to new technologies, the needs of particular populations such as the elderly and the urban poor, replacement of aging physical plants, and the capital requirements for teaching and research. The plan will need to deal with the locus of decisionmaking for these varied needs and with the mix of policies that balance long-term needs with shorter term responses to changing requirements. KNOWLEDGE DEVELOPMENT Databases, Surveys, and Information Technologies Successful implementation of health care reform will require more and better data and information about health care, especially in the face of the pressures that can be expected as a new system tries to hold down

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Assessing Health Care Reform expenditures while expanding access and maintaining high-quality care. Health care providers, patients, the public, and policymakers all will be asked to make harder and more complex choices and trade-offs than in the past. Informed choices dictate a vastly increased need for improved data and information for operations, evaluation, and research. As a case in point, defining and refining an appropriate package of basic benefits would present a stiff challenge even with far more information than we have today about the efficacy and effectiveness of health care services.4 Similarly, a comprehensive quality assurance system will require a greatly enhanced database on the use of services, patient outcomes, and the processes of care. The creation of these kinds of databases, only the foundations of which currently exist, will be a major undertaking. The committee recommends, therefore, that reform proposals include a specific mandate for the development and continued support of comprehensive health databases. These should contain material on access to and availability of care, use of health services and technologies, outcomes of care, demographic information, and information on health plans. These data can be used in health services, effectiveness, and outcomes research, technology assessments, and the evaluation of national and state health care reform efforts. From the time of the first national census in 1790, an important role of the federal government has been to provide objective statistical data to inform and guide decisions and social policies in a free society. In light of the rapid changes in health care now occurring and the prospect of further dramatic change, this federal responsibility becomes even more acute, and it intersects significantly with the previous recommendations concerning research, data, and database. The committee recommends taking steps to improve the nation's survey and statistics capabilities, particularly by instituting a national health care survey that can 4   The distinction between efficacy and effectiveness is important. Efficacy is typically defined as the outcome of an intervention when it is applied in ''ideal'' circumstances, such as those in prospective randomized clinical trials; this is the purview, for instance, of much of the research agenda of the National Institutes of Health. In contrast, effectiveness refers to the outcome of an intervention when applied in the daily practice of medicine to the medical problems of typical patients; research in this area is supported chiefly by the Agency for Health Care Policy and Research.

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Assessing Health Care Reform track progress and identify problems in the implementation of reform efforts. The National Center for Health Statistics has proposed an innovative national survey intended to greatly improve our knowledge about the functioning of the health care system. In Toward a National Health Care Survey: A Data System for the 21st Century (NRC/IOM, 1992b), a joint IOM/NRC committee suggested ways to make this survey an even better source of data about the use and effects of health services—for example, patterns of care, the cost of care, health status and other characteristics of individuals receiving care, and the demand for and use of services over time and across a broad range of providers and service settings. National survey data would complement information derived from health care operations, such as insurance claim forms and hospital discharge abstracts; these sources typically are the core of the kinds of health databases discussed above. National survey data would also supplement information that, in the future, may be derived from computer-based patient records (CPRs) and CPR systems. In a recent report, The Computer-based Patient Record: An Essential Technology for Health Care, an IOM panel explored the problems of today's patient records, which are still predominantly paper based, and the opportunities afforded by a shift to computer-based systems (IOM, 1991b). Universal adoption of CPRs promises all the following: better patient information to support clinical decisions; improved management of care by making quality assurance procedures and clinical practice guidelines more accessible to health care professionals at the time and site of patient care; reduced administrative costs; and more relevant, accurate data necessary for provider and consumer education, technology assessment, health services research, and related work concerning the appropriateness, effectiveness, and outcome of care. The committee recommends that reform proposals promote universal implementation of CPRs and CPR systems among providers. Complete development and adoption of CPRs will be a lengthy and challenging task. Although progress is being made, explicit commitment in health care reform proposals in this area will provide a further impetus to complete this technological and behavioral revolution and to use information and electronic technologies as a lever for progress in controlling costs, expanding access, and improving quality.

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Assessing Health Care Reform To promote related advances in information services and technologies, the committee also recommends adoption of an expanded program in information services for health services research and technology assessment at the National Library of Medicine (NLM). Recent legislation requires the NLM to improve its array of services; to do this, the library has undertaken various developmental efforts in the areas of vocabulary, indexing, and management of databases and other information resources. An IOM committee asked to review NLM activities and plans made several recommendations related to the library's long-term goals (IOM, 1991e). The recommendations involve improving access (including automated access) to a wide range of published and other information important to those who deliver health care and to those who produce and use health services research; promoting use of the NLM's information services by a wider range of audiences and interest groups than has heretofore been the case; and expanding and enhancing the traditional reference, research assistance, coding, and retrieval activities of the library and its national network of libraries. Although the committee does not expect reform proposals to deal with these information technology and services issues in detail, it does express its hope that the need for and utility of the NLM's broad scope of activities will be recognized and supported at least in general terms. Privacy and Confidentiality of Sensitive Personal Health Data Increasingly, concerns about the privacy and confidentiality of sensitive health data are drawing the attention of providers, patient and consumer groups, legal experts, ethicists, and computer specialists (IOM, 1991b, 1993b; Workgroup for Electronic Data Interchange, 1992). Reform plans that rely heavily on health-related, patient-identified information in large databases must acknowledge the social, legal, and ethical problems inherent in these issues and, ideally, propose some steps to protect patients' privacy rights. These safeguards must be strong (and must be perceived to be strong), but they should not interfere with appropriately approved research and system evaluations of the types discussed above.

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Assessing Health Care Reform Health Services, Outcomes, and Effectiveness Research In the health sector, many different types of basic and applied research are needed, and sophisticated biomedical and clinical investigations have long been a hallmark of the research enterprise in this nation. To assure the continued flow of new knowledge about health and disease that will be the basis for more definitive preventive and curative strategies, the remarkable record of biomedical research productivity needs to be sustained. With respect to the looming changes in health care delivery that reform promises, however, greater attention will have to be given to the clinical evaluation sciences, including outcome and effectiveness research, and to health services research. To provide this knowledge and analytic base, the committee recommends an absolute increase in the support for a range of research and information activities that should be carried out if reform is to be implemented and evaluated satisfactorily, particularly in the areas of clinical evaluation sciences and health services research. Several IOM committees have addressed the promises and limitations of research on effectiveness and outcomes in health care (1989c, 1990a,b,e,f). Among the key aspects of effectiveness research are generating accurate, valid, and reliable data; following patients over time and across settings of care; comparing alternative approaches to care; and tracking a broad range of patient-relevant outcomes including self-reported quality of life and health status (Lohr, 1989, 1992). The expansion of the medical effectiveness program of the Agency for Health Care Policy and Research (created in late 1989) was an important step in expanding research on effectiveness and outcomes. Effectiveness research complements the biomedical research that is the scientific substrate of both clinical medicine and clinical epidemiology, which emphasizes the incidence and prevalence of disease. It adds an important dimension to these efforts by helping physicians and other health professionals, patients, the public, and policymakers better understand what can be expected from alternative courses of care, a key requirement for making determinations about value. Therefore, adequate support of effectiveness research, as well as biomedical research, is a necessary and integral part of any health care reform plan that hopes to improve the value received for our investments in health care.

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Assessing Health Care Reform Health services research might be said to comprise a focus on the health status of individuals, populations, or both; review or analysis of health systems, health interventions, and the factors that influence health status; a comprehensive set of variables involving health care techniques, practices, programs, and policies; and the combination and integration of these variables in many ways, frequently emphasizing the nonbiological aspects of health and medical care (IOM, 1991e; see also IOM, 1979). From this listing, the relevance, if not the absolute necessity, of health services research should be clear. The committee believes that reform proposals serious about self-evaluation will make support for such a research agenda a high priority.5 Some proposals, but by no means all, explicitly address issues of quality of care, for instance by suggesting the creation of a national program of quality assurance. Others may directly or indirectly call for efforts at technology assessment, development and application of clinical practice guidelines, and various consumer education and outreach activities. Still others advocate various changes in the nation's approach to malpractice liability (e.g., tort reform as a piece of the larger reform picture). All these matters are within the health services research purview. The committee believes that among the specific areas deserving attention are quality measurement, assurance, and improvement (IOM, 1990h; 1991f) and clinical practice guidelines issues, particularly with respect to techniques of development, methods of dissemination and application, and evaluation (IOM, 1990d, 1992b). Research in selected topics such as aging (IOM, 1991d) and disability prevention (IOM, 1991c) will also be important. Therefore, for purposes of informing the full range of 5   Examples of the questions that reform proposals generate in the area of health services research include: How will reforms affect access to care by different subgroups of those currently insured and uninsured? How will reforms affect total spending on health care, the rate of increase in expenditures, and specific factors that influence spending (e.g., new technology, and the purchase of less generous health coverage)? If a spending cap is adopted, will it work as expected? Will financing mechanisms work as anticipated with respect to their adequacy and as to their effect on the distribution of the financing burden? What unanticipated consequences may also emerge? What major problems with health care will the public and policymakers identify?

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Assessing Health Care Reform health care reform efforts over the ensuing decade, a sustained investment in general health services research equivalent to that for effectiveness research, if not for biomedical research, will be needed. Technology Assessment Hand in hand with clinical evaluation and health services research, as well as biomedical research, go health technology innovation and assessment. Changes secondary to health care reform are expected to affect the use of existing technologies (e.g., through the development of basic benefit packages) as well as to influence the extent and direction of technological innovation. For these reasons, the committee recommends that steps be taken to improve the nation's capacity to execute effective technology assessments and that reform proposals be explicit about how they will deal with the innovation and diffusion of health technologies. Questions about the impact of cost containment on the innovation, development, and diffusion of medical technologies can be expected to arise, so ideally reform packages ought to anticipate these issues even if they cannot at this early stage propose definitive plans for managing technological innovation and change (IOM, 1991g, 1992c). Given the scarce resources available in the public sector for technology assessment, mechanisms for setting priorities for technology assessment deserve attention (IOM, 1992f). Finally, as is true for the development of practice guidelines, quality criteria, and similar informational, educational, administrative, or evaluative tools, some efforts will need to be directed at developing better methods to establish a consensus about good (or poor) health care practices and to carry out appropriate studies of the costs and benefits (i.e., the value) of health care services (IOM, 1990d,g; 1991a). PUBLIC HEALTH POLICIES AND PROGRAMS Health care reform is understandably focused on issues relating to personal health care services. The committee recognizes that many factors that affect the health of the population (e.g., air and water

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Assessing Health Care Reform pollution, personal behaviors affecting health, and protection against personal injury) have a primary locus external to the direct delivery of personal health services. The committee strongly urges that reform proposals explicitly recognize the need for support of the public health sector. In The Future of Public Health, an IOM committee advanced numerous recommendations for strengthening the mission of public health—namely, "fulfilling society's interest in assuring conditions in which people can be healthy" (IOM, 1988, p. 7)—and overcoming the disarray of public health. These recommendations dealt both with structural aspects of public health, including the governmental role in public health and types of responsibility at the federal, state, and local government levels, and with organizational focal points for public health, special linkages (to, for instance, environmental health, mental health, and care for the indigent), strategies for capacity building, and education for public health. A partnership between the personal health services system and the population-based activities of the public health system, as well as occupational health activities, should be encouraged in the reform proposal. This partnership is essential for dealing with many significant health issues, such as AIDS, resistant strains of tuberculosis, unhealthy dietary practices, substance abuse, case-finding and outreach, and emergency services. By explicitly recognizing these important links, the reform proposal can avoid the unintended starvation of public health programs in the competition with health care reform for scarce public funds. OTHER INFRASTRUCTURE ISSUES Programs for Special Populations The earlier discussion of access noted that the needs of special populations may require targeted public programs. It also emphasized that the role of existing public programs, in particular, Medicare for the elderly and disabled and Medicaid for some of the poor, will have to be defined. These are infrastructure as well as access issues.

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Assessing Health Care Reform Tort Reform It is hard for the committee to conceive of successful health care reform over the long run that does not address the real and perceived problems related to our current system for dealing with medical liability for bad clinical outcomes. Reform proposals should, at a minimum, acknowledge these problems and either define general directions for tort reform or specify a process and timetable for defining such directions and translating them into specific policy proposals. This committee, however, lacked the resources to define those directions as they relate to changes in tort law, adoption of alternative structures for dispute resolution, and similar options. The discussion below highlights points raised in IOM reports on quality of care and clinical practice guidelines. A major criticism of the current system for determining medical liability is that it is not a reliable vehicle for screening out or rejecting unwarranted claims of malpractice. The consequences of this unreliability include high malpractice insurance costs, psychological burdens on practitioners, higher health care costs stemming from "defensive medicine" (i.e., care that would not be provided but for the fear of litigation), and even incentives for practitioners to abandon certain kinds of medical practice (e.g., obstetrics). Less prominent in much of the discussion of tort reform is the criticism that the current system leaves much malpractice unidentified and unremedied (IOM, 1991g). Tort reform efforts should acknowledge both criticisms of the current system and should recognize the role of quality assurance programs and other vehicles for responding to elements of these criticisms. First, improved programs of quality assurance and continuous improvement can do much to detect performance problems, identify their causes, and develop administrative and clinical strategies for improving performance and avoiding future problems (IOM, 1990h, 1991g). A preventive approach clearly has advantages over after-the-fact compensation of victims, although the latter is also appropriate. Second, the grievance process recommended in the preceding section of this report may deflect some unwarranted claims of

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Assessing Health Care Reform malpractice. It may also lead to acceptable resolution of some real cases of malpractice without the expense and trauma of a trial. Third, clinical practice guidelines have a role to play in efforts to reduce the incidence of malpractice and to resolve specific claims of medical liability (IOM, 1991g). Some guidelines may target specific sources of malpractice suits (e.g., anesthesia-related injuries). In the context of changing judicial views of the appropriate standard of care, guidelines may help judges and juries better identify bad outcomes due to substandard care. Further, guidelines formulated to help patients better understand the likely benefits and risks associated with treatment alternatives may reduce litigation inspired by poor communication and disappointment resulting from unrealistic hopes. However, another IOM study committee has concluded that it was premature to endorse state legislation granting practitioners immunity from liability if they have practiced in accord with guidelines developed at legislative behest (IOM, 1991g). The committee was concerned about weaknesses in the processes for developing such guidelines and assessing their soundness. It also believed that plaintiffs as well as defendants should be able to cite robust guidelines in their arguments. Malpractice and tort reform are complex issues that perhaps need not be woven directly into health care reform from the outset, although some committee members thought otherwise. The options for malpractice and tort reform go far beyond the points we have discussed above. These options include statutory reforms (such as barriers to suits or reductions in damage awards), arbitration and mediation as alternatives to litigation, no-fault approaches, various kinds of administrative programs that may involve disciplinary (fault-based) actions (like those now in theory done through licensure boards), so-called early offers of settlement (done on a voluntary basis by offending providers and practitioners), mechanisms based on private contracts between providers and patients, and enterprise liability (in which institutions such as hospitals, health plans, or others undertake to cover individual practitioners in malpractice situations). Little or no empirical evidence suggests which of these strategies might be effective in which situations, and hybrid arrangements might also be possible. The committee believes that reform proposals should, at a minimum,

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Assessing Health Care Reform acknowledge the need for change and perhaps indicate what strategies would appear to mesh best with the type of reforms envisioned. Public/Consumer Education Although reform proposals vary in their emphasis on the consumer as an informed purchaser of care or the patient as an informed decisionmaker about courses of treatment, the proposals share a common infrastructure requirement: more extensive and effective public and patient education programs and tools. Market-oriented reforms require explicit attention to the kinds of comparative information provided to individual purchasers of health plans, the source and accuracy of that information, and its real utility. The conditions for effective consumer decisionmaking may also include other changes discussed in this and other IOM reports, for example, some standardization of benefit design and regulation of health plan marketing practices. To educate individuals faced with making decisions about possible courses of care for specific medical problems, clinical practice guidelines that consider outcomes relevant to patients and variations in patient preferences for different types of care and outcomes can—in the form of practitioner guidelines—help physicians and other health care practitioners better educate patients and—in the form of patient guidelines—help directly build patient understanding. New educational media such as the interactive video disc technology may at the same time standardize the information provided to patients and increase its relevance.

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Assessing Health Care Reform IMPROVING THE INFRASTRUCTURE FOR EFFECTIVE CHANGE Key Statements Reform proposals should be clear about the roles, responsibilities, accountabilities, and interrelationships of the public and private sectors in implementing the proposal and achieving its objectives. All reform proposals should provide for greater standardization and efficiency in some administrative tasks. Reform packages should be clear and realistic about the time-table expected for full implementation. Monitoring mechanisms will be needed to detect inadequate implementation, unanticipated negative effects, and positive results that should be built upon. Any plan should make clear how it will deal with issues of human and physical capital supply and distribution. Health care reform proposals should describe policies and priorities that determine the role of various providers, including nurses and physicians, and the settings from which they should deliver care. Particular emphasis must be given to primary care providers and how the shortfall in such clinical disciplines can be overcome both in the near term and over the longer run through changes in practitioner payment methods, educational programs, and improvements in the attractiveness of the primary care function.

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Assessing Health Care Reform Reform proposals should include a specific mandate for the development and continued support of comprehensive data-bases in the health field. The committee recommends taking steps to improve the nation's survey and statistics capabilities, particularly by instituting a national health care survey that can track progress and identify problems in the implementation of reform efforts. Reform proposals should promote universal implementation of computer-based patient records (CPRs) and CPR systems among providers. The committee also recommends adoption of an expanded program in information services for health services research and technology assessment at the National Library of Medicine. The committee recommends an absolute increase in the support for a range of research and information activities that must be carried forth if reform activities are to be implemented and evaluated satisfactorily, particularly in the area of clinical evaluation sciences and health services research. The committee recommends that certain steps be taken to improve the nation's capacity to carry out effective technology assessment efforts and that reform proposals be explicit about how they will deal with the innovation and diffusion of health technologies over time. A partnership between the personal health services system and the population-based activities of the public health system, as well as occupational health activities, should be encouraged in the reform proposal.