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:
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How Should Accountability Be Assigned for the Quality of Health Care? Both internal accountability and external accountability are essential in ensuring the quality of health care. Internal quality-improvement and quality-management efforts to develop and design care and to monitor quality of care are essential. They involve health plans and health systems acting on their own initiative to measure and improve their performance and their patients’ outcomes. Such efforts will also reinforce the steps that physicians and other health care professionals can take now to improve the performance of local health care institutions and health plans. External monitoring of quality of care will also be necessary to ensure the integrity of the quality-of-care information that plans report and to make assessments from a broader population perspective. It is imperative that the impact of health-system changes on the quality of health care and the health status of the entire population be tracked. Both public and private organizations are involved—often cooperatively—in work to devise valid, reliable, and practical ways to measure and compare the quality of care provided by health plans, institutions, and clinicians. These dual accountabilities—internal and external quality monitoring and improvements—are not well understood by the health care community, policymakers, or consumers. They need to be continually refined and reinforced. The multiplicity of public agencies at federal and state levels with oversight responsibility and the range of private organizations that accredit health care organizations and review care, as well as internal quality-improvement efforts of health plans, would lead some to believe that assurance of quality is well in hand. Unfortunately, duplication of effort and gaps in measurement coexist. For example, methods for adjusting health-outcome and performance measures to reflect differences in the age, health status, and other characteristics of health-plan members or other populations are improving but are still inadequate. Without appropriately adjusted comparisons, we can misjudge how well health plans protect and serve their members. The problem of “severity-adjusting” outcome measures parallels the problem of “risk-adjusting” government, employer, or other payments to health plans (in ways that do not rely on those who are ill to pay higher premiums). Without appropriately adjusted payments, we might penalize plans that attract less-healthy and more-costly members (the plans that experience adverse selection). Such financial incentives could undermine efforts to improve quality and hold health plans accountable for their actions. Thus, sound methods to adjust payments to health plans and comparisons of health plan performance for differences in members’ characteristics are essential. For more information:
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Every set of guidelines for clinical practice or statements of best health care practices should cite the strength of the evidence and the expert judgment behind the guidelines and the expected health and cost outcomes of following them. (C-1)
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Medical-review criteria should be open to examination by purchasers, physicians, and others. (C-2)
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A private, nonprofit organization should be established to offer users of guidelines credible and understandable assessments of the strengths and limitations of major guidelines issued by public and private organizations. An assessment guide drafted by the Institute of Medicine should be further tested. (C-2)
What is the role of the computer-based patient record?
Computer-based patient record (CPR) technology is essential for health care. This role begins in the care process as the CPR provides patient information when needed to support clinical decisions and continues as a key information source for quality review and improvement. It can be linked to clinical-practice guidelines, clinical alerts, and up-to-date research findings to help patients and clinicians in making choices. The desire to improve the quality and usefulness of health care data is shared by patients, practitioners, administrators, researchers, and policymakers throughout the nation.
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What Do Privacy and Confidentiality Have to Do with the Quality of Care? Privacy and confidentiality are key elements of ensuring quality in the health care system. To the extent that people worry about the confidentiality of the information that they provide to physicians and others, they might withhold information, thus compromising the quality of their own care, undermining the quality of data used for other purposes, and contributing to a deterioration in trust between patient and physician and between patient and health plan. If people fear that seeking particular kinds of medical services will make their medical history available to employers, credit organizations, and others, they may even avoid seeking needed medical care. Current state protections often apply duties of confidentiality to the recordkeeper (such as a hospital), but these protections are no longer in effect once the data have left the recordkeeper’s control. It is important to note that video-rental records, for example, have more federal privacy protection than medical records. Despite much debate and discussion, several prominent efforts to secure national privacy safeguards have not yet succeeded, although recent legislation may change that. Health data should be protected. Legislation should be enacted to establish the confidentiality of person-identifiable data as an attribute of data elements themselves, regardless of who holds the data. (C-4) The US Congress should enact privacy legislation. Such legislation should
In addition, the Employee Retirement Income Security Act of 1974 (ERISA) should be changed to strengthen protections for employees whose employers have access to personal medical information through health-insurance plans. Employers or their agents have legitimate interests in this information, so Congress should amend ERISA (through provisions analogous to those in the Americans with Disabilities Act), so as to regulate employer access to individual medical information collected in connection with employment-based health benefits. (C-5) ERISA is also a major barrier to legal claims of corporate negligence, no matter how clear the fault and how serious the injury (including death) to patients and families. As a result, one of the ultimate tools to discourage and compensate for low-quality care is denied to many workers and their families. This situation underscores the need for efforts aimed at protecting and improving the quality of health care to be broadly focused in identifying problems and promoting agreement on solutions. For more information:
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Widespread CPR use should be achievable within a decade. Progress has been made, but the goal is elusive. Health care professionals and organizations should adopt the computer-based patient record as the standard for medical and all other records related to health care. (C-3)
What are the responsibilities of organizations that collect health data?
Organizations that hold health databases or are part of networks of health databases have the responsibility to ensure the quality and security of health data. Such health database organizations can be created by business coalitions, built by entities supported with private funds, mandated by state health legislation, or established by federal action. Characteristics of such databases include their linkage of patient events over time, timeliness of data, accuracy and completeness for the uses intended, ownership and oversight, and the use of unique person-identifiers. Health-database organizations should take responsibility for maintaining data quality continuously and take steps to ensure 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. (C-4)
In addition to their benefits, the electronic recording, storage, transmission, and retrieval of patient information have in some respects increased the possibility of infringement on the confidentiality of personal medical information. Such medical information extends beyond the written word to include still images, audio records, and videos of patients, and many more people now have or potentially have access to this information than in the past.
These developments require continuing reassessment of the tradeoffs between privacy concerns and other values, such as convenient and quick access to information, and of the practical realities of enforcing an agreed-on balance of competing objectives.
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For more information on the knowledge base and health care quality:
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Conclusion
Who needs to be well informed and concerned about quality of care?
Everyone needs to be well informed and concerned about the quality of care. Everyone means patients and their families, consumer agents and advocates, health professionals, administrators of health plans and facilities, purchasers of health care services, and policymakers at all levels. The messages to these audiences are 1) that the quality of care can be measured and improved and 2) that quality of care should not be ignored in pursuit of cost control. Reinforcing these messages means making sure that quality of care stays on the health care-delivery agenda, with clear identification of the risks and opportunities that are posed by the changes in health care in the United States. It also means describing how health plans, health care organizations, and clinicians should be accountable to patients and society and, conversely, how individuals can take appropriate responsibility for their own health.
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For Further Information: The World Wide Web site http://www2.nas.edu/21st includes up-to-date versions of all the documents in this series and on-line versions of the reports referred to in this document. Internet Address: jjensen@nas.edu Phone: (202) 334–1601 Fax: (202) 334–2419 Address: National Research Council Office of Congressional and Government Affairs 2101 Constitution Avenue, NW Washington, DC 20418 |
© 1997 by the National Academy of Sciences. All rights reserved. This document may be reproduced solely for individual, non-commercial, and educational purposes without the written permission of the National Academy of Sciences.
