networks needed to incorporate them into day-to-day operations.
Overall, tools for measuring and improving health care must confront three broad kinds of quality-of-care concerns:
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Use of unnecessary or inappropriate care. Examples include the excessive or unnecessary use of x-ray and other diagnostic tests, unnecessary hysterectomies and open-heart surgery, and overprescription of antibiotics and some mood-altering drugs. Those practices make patients vulnerable to harmful side effects. They also waste money and resources that could be put to more productive use.
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Underuse of needed, effective, and appropriate care. People do not get proper preventive, diagnostic, or therapeutic services if they lack health insurance and if they delay seeking care or receive no care at all. Even those with insurance often face geographic, cultural, organizational, or other barriers that limit their abilities to seek or receive care.
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Shortcomings in technical and interpersonal aspects of care. Inferior care results when health care professionals lack full mastery of their clinical-practice fields, do not adequately explain key aspects of care, or cannot communicate effectively with their patients. Cases in point include preventable drug interactions and surgical mishaps, failure to monitor or follow up abnormal laboratory-test results, neglect of appropriate education and information for patients, lack of adequate coordination of care, and insensitivity to ethnic and cultural characteristics of patients. (A-1, A-2)
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For more information on measuring the quality of care:
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Accountability for Quality of Care Under Medicare Should Be Strengthened
What is Medicare’s responsibility for quality of care?
The quality-assurance strategy of the Medicare program (the
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Can Quality of Care Be Defined? Quality of care can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. That definition, formulated by a committee to design a quality strategy for the Medicare program, has been widely accepted and has proved to be a powerful tool in the formulation of practical approaches to quality assessment and improvement. Several ideas in the definition deserve elaboration. The term health services refers to a wide array of services that affect health, including those for physical and mental illnesses. Furthermore, the definition applies to many types of health care practitioners (physicians, nurses, dentists, therapists, and various other health professionals) and to all settings of care (from hospitals and nursing homes to physicians’ offices, community sites, and even private homes). Including both populations and individuals draws attention to the different perspectives that need to be addressed. On the one hand, we are concerned with the quality of care that individual plans and clinicians deliver. On the other hand, we must direct attention to the quality of care across the entire system. In particular, we must ask whether all parts of the population have access to needed and appropriate services and whether health status is improving. The phrase desired health outcomes highlights the crucial link between how care is provided and its effects on health. It underscores the importance of being mindful of people’s well-being and welfare and of keeping patients and their families well informed about alternative health care interventions and their expected outcomes. Current professional knowledge emphasizes that health professionals must stay abreast of the dynamic knowledge base in their professions and take responsibility for explaining to their patients the processes and expected outcomes of care. For more information:
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federal program providing health insurance to elderly people and some people with disabilities) has done much, but accountability for quality remains a concern. Medicare’s quality-assurance strategy should focus on health care
decision making and patient-health outcomes, enhance professional responsibility and capacity for improving care, use clinical practice as a source of information to improve quality of care, and be able to demonstrate positive effects on the public’s health.
Although both public and private programs have moved in those directions, the Medicare program’s responsibility for the quality of care can be strengthened. Congress should expand the mission of Medicare to include an explicit responsibility for ensuring the quality of care of Medicare enrollees. (B-1)
To help to meet that responsibility, Congress should establish a Quality Program Advisory Commission (QualPAC) to oversee Medicare activities and report to Congress. (B-1) QualPAC would guide and advise on quality in ways similar to those used by the commissions that have advised Congress on physician and hospital payment.
Does managed care present any quality concerns for Medicare?
All those providing care to Medicare beneficiaries should be accountable for the quality of care. Managed care presents two key quality concerns for Medicare beneficiaries: health plans need to be more accountable to and understandable by elderly patients, and the necessary protections need to be built into the system to help Medicare beneficiaries to move through the health care system effectively, safely, and confidently in an environment of greater health-plan choice.
Information from a neutral source (neither purchaser nor health plan) relevant to patient and consumer concerns should be much more widely and easily available. (B-2) It will require substantial efforts to build the needed consumer-oriented information infrastructure for Medicare beneficiaries at the national, state, and local levels.
Enrollment and disenrollment guidelines, appeals and grievance procedures, and marketing rules should reflect Medicare beneficiaries’ vulnerability and lack of understanding of traditional Medicare and Medigap insurance, as well as their current mistrust of important aspects of alternative health plans. (B-2)
Payment incentives, gag rules, and other 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 should be abolished or prohibited as a condition of plan participation in Medicare. (B-2)
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For more information on quality of care under Medicare:
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A Carefully-Constructed Knowledge Base Is Needed to Improve the Quality of Medical Practice
Why is knowledge so important?
Quality assessment and improvement are knowledge-driven enterprises. We know far more today than in the past. Yet we still do not know enough about what works in medicine and health care, for what conditions, under what circumstances, and at what cost to improve the quality of health care to the greatest extent possible. Effectively functioning markets require that patients, employers, and other consumers have good information for decision making, including knowledge about the performance of health plans and the efficacy, effectiveness, and cost-effectiveness of health services, both new and established.
Health-services researchers, government agencies, health plans, purchaser coalitions, and others have done much to improve ways of measuring health outcomes, comparing the outcomes of different health care practices, evaluating the performance of health care providers and practitioners, and developing credible and useful guidance for patients and clinicians in making medical decisions. It is important that Congress and private organizations continue to support this knowledge-building work with the joint goals of improving average performance, and correcting substandard practices. (C-1)
Guidelines for clinical practice and tools for assessing clinical performance vary substantially. Several attributes of practice guidelines and medical-review criteria are important for quality health care and public trust:
