Q & A
As AHRQ releases the 10th edition of the annual reports on the quality of health care and disparities in health care, Research Activities (RA) interviewed the main author of the reports for the past decade, Ernest Moy, M.D., M.P.H., a senior research scientist at AHRQ. He discusses how the reports have evolved, what surprised him, and goals for the reports, plus why he's okay with being known as nag.
RA: It's been a decade. How have the reports changed?
Moy: When we first started, we were struggling with measuring important topical areas. For example, we had maybe one or two measures related to mental health care and one or two measures related to HIV and AIDS. We had almost no measures that were not ambulatory care and hospital care. We used a narrower measure set.
Over time, we've identified special data sources to give us information about mental health, drug abuse, and HIV/AIDS. We've greatly expanded attention related to long-term care issues. We have sections now that look at rehabilitation, home health care, nursing homes, and hospice care. We've dramatically expanded the scope of the reports. We try to listen to suggestions and we are constantly evolving the reports. We've added things like the LGBT population recently and we've improved our methods in response to different comments.
RA: How have care quality and access changed in the past 10 years? For example, the latest report on quality shows that access to care has declined.
Moy: Over the last decade, quality of health care has been the tortoise, progressing slowly, but consistently and inexorably. This reflects the dedication of providers and payers applying AHRQ and HHS data and tools to making care safer and more effective. In contrast, through 2009, access to care deteriorated as more Americans found themselves unable to afford health insurance, and many with insurance delayed care due to high out-of-pocket costs. Expanding public insurance only partially met this increased need, especially as workers lost insurance along with their jobs during the recession.
RA: In your 10 years of working on these reports, what has surprised you the most?
Moy: One thing that surprised me is the extent to which disparities exist. When we started, we knew there were many disparities that had been identified. But when we started looking at disparities systematically, we saw disparities exist everywhere. I did not expect the breadth of the disparities issue.
RA: How will this change?
Moy: It definitely will go away—or at least racial and ethnic disparities will go away. Our society is becoming increasingly diverse. The fastest rising group is persons of multiple race, and there will be some time in the future when this group will be the dominant group. Then you just can't really have these disparities in a very sustainable way. The flip side, unfortunately, is socioeconomic status disparities persist. Even in places where they have universal health care systems, like Canada and England, they still have socioeconomic disparities. That's probably the tougher nut to crack.
RA: How do you think these reports will be different in 10 years?
Moy: The first thing I'm looking forward to instead of seeing these shallow lines going nowhere quickly, is seeing a big change in the slope. I'm hoping that the Affordable Care Act will kick in and dramatically change some of the slopes of improvement we're tracking. We're starting to see just the barest glimmer of it as it relates to uninsured patients. Our preliminary data for the 2013 reports are now just catching the very early pieces of it, where insurance is provided to the young adult population. That's starting to be measurable.
Hopefully as other reforms roll out, we'll see a dramatic alteration of insurance status, which for years has been getting worse as people were losing their job-related insurance. We will also see changes in other access-to-care parameters, which in general have been worsening over the last decade. Then sometime in the future, we'd like to see the quality-of-care lines start to improve more dramatically than they currently are. We'll see how it plays out.
RA: Measurements are also important at the State level. Tell us about the State Snapshots, which are compiled from data from the quality and disparity reports.
Moy: The State Snapshots are our tools to help policymakers see quality in higher definition. They help people drill down geographically to the State level. That's where I see us making dramatic changes from year to year.
In the State Snapshots, we aggressively try to track the same measures for disparities that we have in the quality report. I think we largely achieved that, but we're adding more variations at the State level, such as—Does my State have larger or smaller disparities related to income or insurance compared to other States? I hope that States can learn from each other and that they can get together and make improvements.
RA: What motivated you to get involved in health services research?
Moy: When I was doing a general internal medicine fellowship that combined a master's in public health, what hit me right away was that health problems were all about access. It was glaringly obvious that the major thing that was causing problems for people in northern Manhattan and in the south Bronx had nothing to do in general with the care that they were receiving, their genetics, or even their backgrounds to a significant degree. A huge chunk of what was happening to them was related to access to care—not having access to good providers, not having insurance, not being able to pay for this, that, or the other thing needed to be healthy.
Since then, much of my research relates to looking at access to care issues and how they affect different populations. I still think that one of the biggest issues is that Americans continue to have great quality care, but not everyone can get it. Looking at differences across populations, I think, is one way we can motivate people to try to equalize care a little bit and eliminate disparities, and then everybody will get good quality care.
RA: How do the reports help?
Moy: I think that we are viewed broadly in the policy community as the annual nag. They think another year—they're going to nag us and say that there are quality problems, and there are disparities problems again. I think nagging is one of those things that, to some degree, gets people going at times.
RA: So, are you a nag?
Moy: I guess so. Having that chronic person in the background saying, "Oh, don't forget to do something about quality and disparities" serves an important role. I think we're also part of a bigger chorus that is harping on quality and disparity issues. Even though we can't point to concrete dramatic changes, my observation over time is that—at least in the last decade working on these issues—quality has evolved significantly.
When we first started, we heard, "Measuring quality is really hard, and we can't do it, and we're not sure it really helps." Well, we don't hear that anymore. They now assume that not only does quality need to be measured, it needs to be demonstrated. HMOs, employers, insurers, everybody requires you to do it. Instead of "don't measure," we now hear "use this new measure because it is better than that old measure."
The nature and quality of the conversation, I think, has shifted dramatically, and I think quality has improved as a consequence. Disparities have always been a little bit further behind, but I think that it has also evolved along a parallel pathway. We're seeing private organizations and States doing research into quality and disparities. And we have strong initiatives by the Federal Government to try to request that people who receive Federal monies collect information about race, ethnicity, and language so we can target interventions and address this issue more seriously.
RA: You sound optimistic.
Moy: I am. The underlying context for this is that every year we see quality of care improving. Every year, it's up 2 percent, up 2 percent, up 1 percent, up 3 percent. If you look over a decade, it's a sizeable amount. We've seen improvements of 15 to 20 percent, if you sum them up over a decade. And that's the context. It makes sense that providers want to deliver good quality care and insurers want to purchase good quality care. Therefore, even if we just keep on doing what we're doing, we're heading in the right direction.
RA: And what about disparities? Do you see that same gradual improvement?
Moy: In disparities, we've seen less improvement. Although if you examine our data with a very fine-toothed comb, you start to see that more disparities are reducing than increasing. Most disparities aren't really changing to a significant degree, but if you look at the extremes of what's getting better and what's getting worse, more of it's getting better than getting worse.
One of the big impediments with this disparities issue is that in our society, minorities tend to have lower socioeconomic status and to have more problems getting insurance. Not dealing with the insurance issues in our country has been a major impediment. But with the Affordable Care Act, we hope that that will take away a major barrier at least for many minorities.
RA: How do you view the ultimate goal of the reports?
Moy: I think the goal of these reports is to make them no longer essential. If we can achieve a culture in health care where people always think about how to improve quality and reduce disparities whenever they deliver care, then these reports will no longer be necessary. I think the goal is to nag until we achieve victory, and then we can go away.