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OCR for page 43
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.
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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
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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
Representative terms from entire chapter:
health status
