Transcript Don't let the perfect... - Institute for Public

The Business of Health Care
Improving Health through Healthcare
Policies and Quality Standards
The IOM Report Five Years Later:
The End of the Beginning
Based on a presentation made by
Robert M. Wachter, MD
Author of “Internal Bleeding” &
Professor and Associate Chairman, Department of Medicine
University of California, San Francisco
Chief of the Medical Service, UCSF Medical Center
Presentation made at
The Commonwealth Fund Quality Improvement Colloquium
Patient Safety Five Years after “To Err Is Human”
Washington, D.C.
November 4–5, 2004
www.cmwf.org
“There is abundant evidence
that serious and extensive
quality problems exist
throughout American
medicine.”
Institute of Medicine,
1999
Evidence 1: Quality of Health Care
Delivered to Adults in the US – 2003
RAND Study

Methods
» Study of >6700 participants in 12 metropolitan areas
» 439 indicators of quality for 30 conditions

Selected Findings:
» 46% did not receive recommended care
» 11% received potentially harmful care
» Only 24% of diabetics received 3 or more glycosylated
Hgb tests over two-year period
» 65% of hypertensives receive recommended care
» Only 45% of persons with MI (myocardial infarction)
receive beta-blockers
McGlynn et al, N Engl J Med 2003; 348:2635-45
Evidence 2
Geographic Variations in Medicare
Spending & Quality Measure
Information Source: Medicare Payment Advisory Commission
(MEDPAC) Report to Congress
June 2003
Enough to Purchase a Lexus
“In some regions of the United States Medicare pays more
than twice as much per person for health care as it pays in
other regions. For example, age-, sex-, and race-adjusted
spending for traditional, fee-for-service (FFS) Medicare in
the Miami hospital referral region in 1996 was $8,414–
nearly two and a half times the $3,431 spent that year in
the Minneapolis region…
The difference in lifetime Medicare spending between a
typical sixty-five-year-old in Miami and one in Minneapolis
is more than $50,000, equivalent to a new Lexus GS 400
with all the trimmings.”
But does using more care mean better quality? Not exactly.
Higher service use is correlated with lower quality of care ....
The Root Causes
 Errors
flew under the radar screen
 The absence of an incentive system
» Business, educational, marketing… anything
 The
bizarre organizational dichotomy of
American medicine (doctors – hospitals)
How have we done – focus areas for
improvement:
Regulations (NCQA & JCAHO)
 Reporting Systems
 Teamwork Training and Simulation
 Clinical Information Technology (May 2004 
appointment of Dr. David Brailer PhD as the first-ever
national health information technology czar.)
Malpractice and Other Venues for Accountability
 Workforce Issues

Competitive Advantage

The healthcare system needs a strong competitor to
demonstrate a more quality product, this way other
health providers have something to strive toward.
– Ex. In the 1970’s the US was producing low
quality, and sometimes dangerous cars. Toyota
set a standard for inexpensive, safe, reliable,
and quality cars. This caused the US auto
industry to reexamine their product and make it
better.
Market Demand and Public Policy
In order to illicit change consumers need to
demand regulation of health plans and enact public
policy for quality care.
 The government is the largest purchaser of health
care and can be the most effective catalyst for
quality improvement.

Strategies for Healthcare Reform
Require that health plans report standardized
information on quality of care (report cards)
 Push public policy makers and government officials
to develop national standards for reporting
comparable data.
 Encourage consumers to select higher-quality
providers and restrict entry of providers that do not
meet the national standard.
 Make quality improvement a core business strategy.

NCQA & JCAHO
What is the Joint Commission on
Accreditation of Healthcare
Organizations
JCAHO’s Mission
To continuously improve the safety
and quality of care provided to the
public through the provision of health
care accreditation and related
services that support performance
improvement in health care
organizations.
Name,
Blame,
Shame
1992 Mortality (%)
CABG Mortality By State
NY
Annual Rate of Decline 1987-92 (%)
HEDIS 2001-- 52 Measures across
7 Domains

Effectiveness of care (e.g. childhood immunizations,
mammography screening, advising patients to quit
smoking)
Access (translators, timeliness of prenatal care)
 Satisfaction (CAHPS survey)
 Health plan stability (practitioner turnover)
 Use of services (e.g. well child visits, frequency of
selected procedures)
 Informed health care choices (e.g. management of
menopause)
 Health plan descriptive information (e.g. board
certification, practitioner compensation)

Problems with HEDIS / Report Cards
 HEDIS
contains no risk adjustment
» Incentives to avoid the sick and those of lower
socioeconomic status
 Quality
measures: structure, process, &
outcomes. Most report cards focus on process
measure.
Problems With Report Cards
(cont’d)
 Information
can mislead consumers if
it magnifies clinically unimportant
differences
 Complex patterns of quality data may
confuse consumers
 Purchasers, providers and consumers
often want different information…