FOCUSING ON QUALITY IN A CHANGING HEALTH CARE SYSTEM
Concerns about quality could frustrate important changes in health care delivery and financing. Policymakers, payers, managers, and others must confront current and potential quality-of-care problems with the same vigor and sophistication that they are directing to issues of cost. This message applies to public and private sectors alike and to federal, state, and local governments.
Introduction
At its best, health care in the United States is superb. Such care—including prevention, early diagnosis of illness, and advanced therapeutic services—is not, however, available to millions of Americans who are uninsured or underinsured. Even Americans with insurance, including Medicare and Medicaid, may not always have access to adequate care. At the same time, some Americans may be subjected to inappropriate or unnecessary procedures.
American health care—with its mix of superb and questionable care and its gaps in access—is very expensive. Continued efforts to limit the growth of health care spending are essential if we are to meet other socially important needs, for example, in education, housing, transportation, and economic development. Trying to balance cost-cutting initiatives with efforts to maintain and improve the quality and availability of care is a major challenge and requires good information for policymakers, patients, consumers, and others to use in judging whether we are on the right course.
One prominent, and increasingly common, strategy is managed care, a simple label for a diverse and complex array of financial, administrative, and educational programs and tools that attempt to balance cost, quality, and accessibility. Managed-care approaches, which include health maintenance organizations (HMOs), are increasingly the choice for both the privately insured and those covered by Medicare and Medicaid. Some fear that the shift to managed care will produce long queues for care, reduce the availability of effective treatments and technologies, or lessen the personal commitment of physicians, nurses, and other caregivers to their patients. Others believe that managed care, properly designed and implemented, will provide more rational, effective, and affordable health care.
Several key objectives set forth in reports of the Academy complex can help guide the development and implementation of public policies that will ensure the quality of health care provided to Americans. Among these objectives are the following:
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Confront current and potential quality-of-care problems with the same vigor and sophistication that are being directed to issues of cost.
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Expand the mission of Medicare to encompass an explicit responsibility for ensuring high-quality care for Medicare enrollees, including the establishment of a Quality Program Advisory Commission to oversee Medicare activities and report to Congress.
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Make information that is relevant to patient and consumer concerns more widely and easily available.
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Be sensitive to Medicare beneficiaries’ vulnerability and lack of understanding of traditional Medicare and Medigap insurance.
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As a condition of plan participation in Medicare, prohibit practices that might motivate providers to evade their ethical responsibility to give complete information to their patients about their illness, treatment options, and plan coverage.
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Continue efforts to improve average performance and correct substandard practices.
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Develop better methods to adjust payments to health plans and to compare health plans’ performance, so as to properly account for differences in members’ characteristics.
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Adopt the computer-based patient record as the
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standard for medical and all other records related to health care.
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Ensure that health-database organizations take responsibility for maintaining data quality, particularly by taking steps to evaluate the completeness and accuracy of the data in the databases for which they are responsible, as well as the validity of data for the analytic purposes for which they are used.
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Enact legislation to establish the confidentiality of person-identifiable data as an attribute of data elements themselves, regardless of who holds the data.
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Amend the Employee Retirement Income Security Act of 1974 (ERISA), through provisions analogous to those contained in the Americans with Disabilities Act, so as to regulate employer access to individual medical information collected in connection with employment-based health benefits.
Measuring the Quality of Care is Necessary to Promote Improvements
Tested approaches already exist for measuring variations in the quality of some types of care. For more than 25 years, experts have been working to create reliable, valid ways to
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Nursing Homes and Health Care Quality Many Americans will one day have to enter nursing homes. What is the quality of care in those nursing homes? Are the horror stories that are occasionally reported accurate depictions of common occurrences? Will increasing the quality of their care make them unaffordable through Medicare and Medicaid? Despite recent improvements in nursing-home quality and regulatory compliance, the quality of care provided by some nursing facilities leaves much to be desired. Frequently cited problems include inadequate care plans, unsanitary and hazardous environments, and unsanitary food. There is also a failure to maintain the dignity of and respect for patients. Although the use of restraints (which decrease muscle tone and increase the likelihood of falls, incontinence, ulcers, depression, confusion, and mental deterioration) has been decreased, a number of facilities still fail to recognize and promote the independence of residents. Many residents of nursing homes have serious disabilities and problems that need skilled nursing care. Although a licensed nurse (LN) must be on duty 24 hours per day, current regulations require a registered nurse (RN) to be on duty only 8 hours per day. Nurse assistants constitute 70–90% of the nursing staff in nursing facilities. They provide most of the direct care and spend the most time with residents, but they are the least trained. Yet, in 1993, 48% of all nursing-facility residents were chairbound, and 5% were bedfast; 37% had some severe irreversible psychiatric condition (such as Alzheimer’s disease), and another 33% were receiving psychoactive medication for such conditions. This situation indicates the need for careful reviews to determine whether quality of care is adequate. Greater RN presence on all shifts should lead to higher rates of patient survival, improved ability of residents to function independently, fewer hospitalizations, and earlier discharge from nursing homes. The additional cost of boosting RN coverage from 8 to 24 hours per day might be reduced by the potential long-term savings from better-quality health care. For more information:
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assess the quality of care of a wide range of inpatient and outpatient services given for a broad array of health and medical problems. For some health care fields, well-understood measurement tools can be put to immediate, wide-spread use; in others, the science of quality measurement is relatively elementary, making the validity of comparative assessments suspect.
Good ways also exist for improving the quality of health care. In addition to what we know about measuring high- and low-quality care, systems and management research (involving such fields as organizational behavior, statistics, psychology, and learning) can be used to evaluate the outcome of health care decisions and thus influence favorably the institutions and people that provide health services. Organization-wide quality-improvement efforts are beginning to be adopted in the service sectors around the world. Much remains to be learned about linking these concepts and tools, most of which are not yet familiar to clinicians or health administrators, to other, better-known disciplines and approaches in health, such as technology assessment, practice guidelines, clinical evaluation, and medical decision making, as well as to the databases and
