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III. THE FUTURE OF QUALITY ASSURANCE Quality assurance will be a major social experiment. These programs have some potentially predictable benefits for betterment of the population's health status. But they also pose possibilities for unintended consequences, which at very least should not come as a complete surprise. Anticipating the Unexpected High expectations for quality assurance are not neces- sarily bolstered by the record of other recent social programs. The results of most social programs have been less than ex- pected by their proponents, and in some instances have run counter to the intended social direction. For example, the intent of the Federal Housing Administration program was to provide money for new housing and expand the eligibility of people who could not afford housing. It accomplished both aims, but it also accelerated the flight of the white middle class from the city and intensified the geographic gap between blacks and whites. The committee believes that before any quality assurance system is implemented, an attempt should be made to anticipate the unintended results so as to minimize their adverse effects. There are at least six potential un- intended results identified-by the committee. 1~ Standards and 408 ts. The delivery of health care has not been measured against national standards except those em- bodied in case law as a result of malpractice litigation. The promulgation of standards may give rise to probe ems. The standards may be set too low and also may be so inflexible as to retard innovation. It is essential that standards be sub- jected to frequent re-examination so that medical care remains a dynamic and evolutionary process. Since little is known about the relative performance of providers, any initial attempt to set national standards for the provision of care will automatically establish a baseline of processes. If the standards, intentionally or not, exceed the quantity of services in prevailing practice, the inevitable effect will be to increase costs or reduce access. This poten- tial problem leads to another. The rhetoric in Congress and elsewhere about improving the quality of care seems to be in Jarge part based on a con- cern with cost containment. If adherence to standards results in inflation of costs of services being provided, it may appear politically necessary for Congress to reduce the costs by re- ducing the standards. The quality assurance program may also demonstrate unmet needs for services, requiring additional 43
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resources to achieve the desired standard for the entire popu- lation. The quality assurance program should allow a distinc- tion to be made between these two causes of increased costs. 2 ) Administrative problems. Quality assurance is complex and undoubtedly will be a difficult program to administer. Ad- ministration by the government, or any large bureaucracy, is often characterized more by adherence to rules and maintenance of structure than by sensitivity to the need for evolutionary development based on experience. But there are two character- istics that must mark the administration of quality assurance. First, the administration must be sufficiently efficient so that the review process does not result in large case backlogs. Second, any administrative agency with the responsibility for quality assurance must recognize the importance of periodic re- vision of the standards against which providers are to be measured. 3) the patient's responsibility. One of the unfortunate by- products of the technical advances of modern medicine is the progressive loss by the patient of responsibility for his own health, although the patient's actions may significantly affect his health status. But in the area of quality, given the com- plexity of quality assurance systems, unless consumers grasp the purpose of quality assurance as well as understand the mea- sures utilized, their helplessness may increase rather than decrease. The committee has recognized this fact by recommend- ing nonprovider participation in the review process as well as the disclosure of information about the performance of providers. 4 ) Phy s i o fan di s tri bu ti on effe o ts . Through the promulga- tion of national standards for medical care, providers in rural or urban areas that lack adequate medical care resources may face difficulties in achieving compliance with quality assur- ance standards. One result may be an exacerbation of the geo- graphic maldistribution of physicians as those in underserved areas are given further incentive to leave. 5 ) PitfaZZs of teeknoZogy . The use of new technology is widespread in the health care system. While much of it prom- ises improved care, some of it poses problems. The computer can be used as an example. High levels of accuracy can be achieved with computer technology, but the fact remains that errors are made. Moreover, most providers are unfamiliar with the computer and its limitations. If too sophisticated a set of specifications for quality assurance are promulgated, accelerated use of the computer may result in much error. Thus the computer, while offering the prospect of increasing physician performance, may at the same time introduce in- equities and distortions in assessing that performance. 44
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6) Wealth maintenance organizations (H~OsJ and quality assurance. An implicit premise of the PSRO program is that quality assurance will result in cost savings. While over- utilization has been documented in many instances, and while it is true that the PSRO program, or any quality assurance program, should be successful in curbing overutilization if appropriate standards are developed, overutiJization is not the only problem in quality. Physician-generated overutiliza- tion is a quality problem when fee-for-service is the financ- ing mechanism. But when the financing mechanism is on the basis of a fixed amount per capita determined in advance, rather than fee-for-service, there may be an incentive to the providers for underutilization, as well as some patient- generated overutilization. While this concern exists about the incentives under an HMO arrangement, we note that in avail. able analyses of prepaid group practice experiences, the protc- type to the HMO concept, there is little documentation of a problem with underutilization or consumer overuse under this arrangement. One of the fears of the proponents of the HMO is that the imposition of quality assurance standards designed to detect and deter overutilization will unnecessarily burden the HMO, where overutilization is generally not a problem, although underutilization may be. Hence, unless quality assurance pro- grams can be designed to take into consideration the twin problems of over- and underutilization, it is possible that the HMO version of the delivery of health care services may be placed at a disadvantage by quality assurance programs that "look for the wrong thing." What Can We Hope For? A carefully tailored quality assurance program, organized around the principles elucidated in this report, should result in some clear benefits. First, and perhaps most important, is improvement in the performance of the providers of health care, concomitant with satisfaction of the needs and demands of the public for health services and eventual improvement in the health status of the population. Achievement of this, however, is de- pendent upon the optimization of effective care--and the mini- mization of care that is ineffective or harmful. This can be accomplished only by using methods that relate the outcome of care to the processes employed by providers. Quality assurance may also make it possible to redefine health care. There are many factors that influence health and health care in the traditional therapeutic sense is only one of them. For example, if low-fat diets and the elimination of lead paint poisoning are shown to have greater impact on health status than heart transplants or treatment of acute 45
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lead poisoning, it can be argued that health care should re- define what it is, what it--~-oes, and how its resources are deployed. If the health sciences are to deal with health, then it also can be argued that the educational content for health practitioners must be broadened to include the full range of variables that affect health and the wise utilization of scarce resources. Reduction in the cost of providing the current range of health care services may be achievable if the methods employed in quality assurance are successful in winnowing effective-care from ineffective care with a resultant diminution in the pro- vision of those services for which little or no evidence is available as to their efficacy. The resources we save by sup- porting only effective care could then be redirected to the amelioration of other conditions that have demonstrable impact on health status, such as poor housing, air pollution, noise, and other social and environmental influences. Funds also could be allocated more generously to the "caring'' components of medicine, particularly for dependent people, children, the aged and the permanently disabled. Quality assurance programs could also reduce some of the current inappropriate dependence on technical rather than personalized care. Finally, another benefit of quality assurance might be a more enlightened consumer. Given the technological sophistica- tion of care and the complexity of delivery systems, consumers have become steadily more bewildered about health care and in- deed about health itself. The average consumer tends to equate health with medicine; he expects much of providers and little of himself. The involvement and participation of consumers in quality assurance should give them an appreciation of what medical care can and cannot do, and a better understanding of what they can do to protect their own health. Although better care may be the prime objective of quality assurance, an en- lightened population that understands more about health may be an even greater achievement. 46