The Challenge and Potential for Assuring Quality Health Care for the 21st Century
On June 17, 1998, Vice President Al Gore launched the planning committee that will create the Forum for Health Care Quality Measurement and Reporting in the private sector. In March 1998, the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry proposed that the Forum serve as a vehicle to develop a comprehensive national plan for quality measurement, data collection, and reporting standards. As envisioned, it would periodically endorse core sets of measures for standardized reporting of health care quality.
To highlight the potential for quality measurement activities to yield improved health care, the Vice President released this Department of Health and Human Services report, The Challenge and Potential for Assuring Quality Health Care for the 21st Century. The report notes the wide-ranging quality problems in the health care industry. To address these problems, the report makes the case for a nationally coordinated approach to quality measurement and reporting and the important role that the Forum could play. It demonstrates that public and private sector quality improvement efforts spawned by measurement and reporting improve the delivery of care, reduce mortality and morbidity, or enhance the quality of life.
The Forum planning committee will meet during a 6-month period to resolve issues of governance, organizational structure, and financial support for the Forum. More information on this planning committee can be obtained by contacting The United Hospital Fund at (212) 494-0722.
Evidence of Quality Problems
From Quality Measures to Quality Care: Examples of Quality Improvement at Work
Private Sector Efforts in Value-Based Purchasing and Quality Improvement
Why We Need a National Effort to Improve Quality
Proposing a Forum for Health Care Quality Measurement and Reporting
Planning for a Forum
In its landmark report to President William J. Clinton, the Advisory Commission on Consumer Protection and Quality in the Health Care Industry called for a "national commitment to the measurement, improvement, and maintenance of high-quality care for all Americans." As part of that effort, the Commission called for the creation of a Forum for Health Care Quality Measurement and Reporting "to develop and implement effective, efficient, and coordinated strategies for ensuring the widespread public availability of valid and reliable information on quality."
This report documents some of the existing quality problems in the health care system and identifies current strategies that have proven effective at improving quality outcomes, increasing confidence, and often reducing health care costs. It also underscores why a national effort is needed to improve the quality of health care.
Confronting Quality Problems
There are several areas where the quality of American health care is falling short, including underuse, overuse, misuse, and variation in use of health care services.
Underuse of Services: The failure to provide a needed service can lead to additional complications, higher costs, and premature deaths. For example, a study of heart attack patients found that nearly 80 percent did not receive life-saving beta-blocker treatment, leading to as many as 18,000 unnecessary deaths each year. A survey of managed care plans by the National Committee for Quality Assurance (NCQA) found that 60 percent of diabetics age 31 and older had not received a recommended eye exam in the previous year. The same survey reported that 30 percent of women age 52 to 69 had not had a mammogram in the previous 2 years, and 30 percent of women between ages 21 and 64 had not had a Pap smear in the previous 3 years, despite the fact that early screening reduces mortality.
Overuse of Services: Unnecessary services add costs and can lead to complications that undermine the health of patients. For example, half of all patients diagnosed with a common cold are incorrectly prescribed antibiotics. Overuse of antibiotics has been shown to lead to resistance and as much as $7.5 billion a year in excess costs. Another study found that 16 percent of hysterectomies performed in the United States were unnecessary.
Misuse of Services: Errors in health care delivery lead to missed or delayed diagnoses, higher costs, and unnecessary injuries and deaths. A study of New York State hospitals found 1 in 25 patients were injured by the care they received and deaths occurred in 13.6 percent of those cases. Negligence was blamed for 27.6 percent of the injuries and 51.3 percent of the deaths. Based on this study, researchers estimated that preventable errors in hospital care led to 180,000 deaths per year. Researchers estimate that as many as 30 percent of Pap smear test results were incorrectly classified as normal.
Variation of Services: There are significant variations in the practice of medicine across the United States, among regions, and even within communities. For example, hospital discharge rates are 49 percent higher in the Northeast than they are in the West. A person with diabetes is one-and-a-half times as likely to get a needed eye exam in New England than in a Southern state.
The Role of Quality Measurement in Improving Care
In the last decade, Federal and State governments, private employers, health insurers, health plans, health care professionals, labor unions, and consumer advocates have developed successful strategies to measure and improve the quality of health care. For example:
- The New York State Department of Health releases data on the quality of heart bypass surgeries at all of the hospitals in that state. Use of these data has helped reduce mortality in bypass cases by 50 percent in 5 years.
- A Michigan hospital has reduced complications due to drug reactions in their cardiac care unit by 80 percent. At the LDS Hospital in Salt Lake City, Utah, a quality improvement program decreased adverse drug reactions related to antibiotics by 75 percent.
- An asthma program in Boston has led to an 86-percent reduction in hospital visits and 79-percent reduction in emergency room visits. In 1992, asthma led to 468,000 hospitalizations in the United States and an annual cost of $6.2 billion.
- The use of NIH guidelines has led to a 100-percent increase in the use of a drug to prevent death among premature babies.
- Minnesota hospitals have increased the use of beta-blocker therapy to prevent second, often fatal, heart attacks in patients by 63 percent through provider education and performance feedback.
Private employers and health plans have also used quality measurement and reporting to improve care and inform consumers. For example:
- General Motors provides its employees with report cards rating health plans' quality of care. The reports include quality measures, satisfaction ratings, accreditation reports, and reports from site visits.
- The Pacific Business Group on Health requires health plans to set aside 2 percent of the premiums they receive and only allows high-performance plans to retain those funds.
- The United Auto Workers requires all health plans serving its members to be accredited by the NCQA.
- Kaiser Permanente of Southern California has launched its "Intervention for Employment Maintenance for Members with End Stage Renal Disease," to help patients cope with this life-threatening illness and continue to work during treatment. Workers in the Kaiser program were 2.8 times more likely to maintain employment.
The Need for a National Effort
While there have been successful efforts to improve health outcomes, increase confidence, and reduce costs, the President's Commission noted that current efforts "vary widely in their aims and scope and have been, at best, only informally coordinated." In some areas, such as chronic disease, very little is being done to measure quality. In other areas, health plans are being overwhelmed by conflicting and redundant requests. The Commission's call for the creation of a Quality Forum is designed to accomplish the following:
- Identify core sets of quality measures for standardized reporting by all sectors of the health care industry.
- Establish a framework and capacity for quality measurement and reporting.
- Support the focused development of quality measures that enhance and improve the ability to evaluate and improve care.
- Make recommendations regarding an agenda for research and development needed to advance quality measurement and reporting.
- Ensure that comparative information on health care quality is valid, reliable, comprehensible, and widely available in the public domain.
The Commission recommended that the Forum be broadly representative of key stakeholders in health care, including: public and private purchasers, consumers, health care providers, health plans, labor unions, and experts in quality measurement and reporting. The Forum will help eliminate duplicative and overlapping demands for information from health care providers and plans, and it will provide consumers and other purchasers with a common yardstick to make direct comparisons of health plans, hospitals, nursing homes, or physicians. Because purchasers will be speaking with a more unified and pragmatic voice on quality information needs, accreditors, plans, and providers will be able to be much more responsive. This progress will help assure that health plans will compete on the basis of quality, not just cost and benefits.
Millions of Americans receive high-quality health care services. The United States has many of the world's finest health care professionals, academic health centers, and other research institutions. However, too often, the quality of care provided to patients is substandard. Too often, patients receive excessive services that undermine the quality of care and needlessly increase costs. At other times, they do not receive services that have proven to be effective at improving health outcomes and even reducing costs.
For example, one study found that only 20 percent of eligible patients received beta blockers following a heart attack, despite the fact that they have been proven to be an effective intervention, reducing mortality by 43 percent (Soumerai, et al., 1997). Another study found that antibiotics are frequently over-prescribed, contributing to microbial resistance to these drugs (Gonzales, et al., 1997). Such resistance could cost as much as $7.5 billion a year for more expensive health care interventions (Phelps, 1989). Moreover, there is still an unacceptable rate of errors; one study estimates that preventable errors in hospital care lead to 180,000 needless deaths each year (Leape, 1994). There is also a wide variation of medical practices across the country. For example, hospital discharge rates were 49 percent higher in the Northeast than in the West (Graves and Gillum, 1997).
Poor quality care leads to sicker patients, more disabilities, higher costs, and lower confidence in the health care industry. As this report clearly documents, there is great potential to improve the quality of the Nation's health care system, and there is widespread interest among representatives in the health care system to make these improvements.
Consumers want understandable and reliable information to help them make critical decisions about their health care. Most Americans consider it very important to know how well their health plan cares for members who are sick, catches health problems at an early stage, and keeps members as healthy as possible. In fact, 90 percent consider how well their health plan takes care of members who are sick very important, and 90 percent consider it very important to know how easy their health plan makes it for members to get the care they need (AHCPR-Kaiser, 1996). However, the vast majority of Americans did not see any information comparing the quality of health care plans, doctors, or hospitals within the last year.
Private and public purchasers have also demonstrated that they want more information about the quality of the care they purchase for their employees, their dependents and beneficiaries as well as new strategies to improve it. As this report illustrates, many private purchasers are developing quality improvement programs, report cards, and other measurement tools to help assure that they can purchase health care based on quality, not just cost and benefits. For example, GTE provides its employees with report cards so they can choose a plan based on cost and quality, and the Pacific Business Group on Health requires HMOs (health maintenance organizations) to set aside 2 percent of the premium dollar and allows plans to keep that money only if they attain the performance standards set in customer service, quality, data collection, and other areas.
Other efforts have emerged to measure and report on health care quality that have begun to provide consumers and purchasers the information they need to purchase quality health care and to enable health professionals and others to develop targeted strategies to improve care. Businesses as well as government agencies are working with health care providers, health insurers, health plans, accreditation organizations, labor unions, and others to encourage the development of these efforts. This report shows that where these representatives have come together to make targeted efforts to improve the quality of care, they have been successful in improving health outcomes, increasing confidence, and often lowering costs.
Some successful strategies have been identified and implemented, but there is clearly a need for a national effort. In its Final Report, the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry commends the investment in quality measurement and reporting made by some of the leading organizations in the field. But it notes that, "despite a growing number of efforts to measure and report on health care quality, useful information is neither uniformly nor widely available." Current efforts, the Commission added, "fall short of fully meeting users' needs and often are duplicative and unduly burdensome on health care providers, plans, and others." The Commission calls for "a national commitment to the measurement, improvement, and maintenance of high-quality care for all citizens."
While there has been a patchwork of successful efforts to improve health care quality, the current system leaves many gaps, and in many other cases is redundant. Moreover, there is no mechanism to share best practices and successful strategies; many purchasers simply do not have the information they need to assure they can purchase health care on the basis of quality, and not just what it costs or what it covers.
To address these concerns, the President's Commission called for the creation of two complementary entities to advance efforts to measure and report on health care quality: a public sector Advisory Council on Health Care Quality and a private sector Forum for Health Care Quality Measurement and Reporting. President Clinton has called on Congress to create a Quality Council through legislation, which would establish national goals to improve health care quality and develop strategies to achieve them. He has asked Vice President Al Gore to help assure the development of the private Quality Forum that would bring together the public and private sectors to identify a core set of measures to be adopted by health plans across the country that would ensure that, for the first time, consumers have a consistent set of standards so they can choose health plans based on quality, not just on cost.
The Council and the Forum are part of the Quality Commission's overall recommendations to improve the quality of health care. In its first report to the President, the Quality Commission recommended a patients' bill of rights to assure that all Americans get the protections they need in a changing health care system. The Commission's recommendations build on the Administration's longstanding commitment to increase access to and improve the quality of health care. For example, last year the President enacted the largest investment in children's health care as well as unprecedented Medicare reforms that extended the life of the Medicare Trust Fund for a decade while improving plan choices and preventive benefits. However, access to health insurance is, of course, not sufficient to assure quality of health care.
As envisioned by the Commission, the Quality Forum will build the systemwide capacity to evaluate and report on health care quality. For the first time, representatives of private and public purchasers will work hand in hand with consumers, providers, and other interested parties to develop a comprehensive plan for implementing quality measurement, data collection, and reporting standards and ensure the widespread availability of this type of information to consumers, providers, purchasers, and others.
The Forum will help eliminate duplicative and overlapping demands for information from health care providers and plans, and it will provide consumers and other purchasers with a common yardstick to make direct comparisons of health plans, hospitals, nursing homes, or physicians. Because purchasers will be speaking with a more unified and pragmatic voice on quality information needs, accreditors, health plans, health professionals, and providers will be able to be much more responsive. In so doing, it will help assure that health plans will compete on the basis of quality as well as cost and benefits.
Evidence of Quality Problems
While millions of Americans receive high-quality health care services, there are a number of areas where the quality of care is falling short. This section documents some of these quality problems including underuse, overuse, misuse, and variation in use of health care services.
Underuse of Services
The failure to provide needed health care services often leads to unnecessary complications, higher costs, and premature mortality. There are numerous examples where services that have proven effective in improving care and often lowering costs are not being used. They include:
Diabetes Care. People living with diabetes require annual eye exams to avoid potential blindness (NIH, 1998). Yet, in its survey of managed care plans, the National Committee for Quality Assurance found that only 40 percent of diabetics age 31 years and older had received an eye exam during the previous year (NCQA, 1997).
Mammograms. Early detection of breast cancer through mammograms can prevent up to 30 percent of breast cancer deaths each year (CDC, 1998). However, NCQA found that 30 percent of women age 52 to 69 in surveyed managed care plans had not received a mammogram in the previous 2 years (NCQA, 1997).
Cervical Cancer Screening. As a result of early detection efforts, the incidence of invasive cervical cancer has decreased (CDC, 1998). Yet in 1996, nearly 30 percent of women between the ages of 21 and 64 had not received at least one Pap smear in the previous 3 years (NCQA, 1997). In 1998, an estimated 13,700 women will be diagnosed with cervical cancer and 4,900 women will die from the disease.
Heart Attacks. The use of beta blockers after heart attack has been shown to reduce mortality by 43 percent. Yet, in a sample of Medicare patients in New Jersey, only 21 percent of eligible patients received beta blockers (Soumerai, et al., 1997). Dr. Mark Chassin at the Mount Sinai School of Medicine has estimated that more consistent use of beta-blocker therapy could prevent an estimated 18,000 deaths each year (Chassin, 1997). The use of aspirin after heart attacks has also been shown to reduce mortality. But, in one study, a third of Medicare patients who survived a heart attack failed to receive aspirin within 2 days of hospitalization (Krumholz, et al., 1995).
Overuse of Services
Excessive and unnecessary health care services can increase health care costs without improving health and can place patients at greater risk for injuries and complications. Examples of overuse of services include:
Antibiotics. In 1992, half of all patients diagnosed with a cold and two-thirds of patients diagnosed with acute bronchitis received antibiotics (Gonzales, et al., 1997). Yet antibiotics offer little or no benefit for these conditions. In that year, 12 million antibiotic prescriptions were written during office visits for colds, upper respiratory tract infections and bronchitis. These prescriptions accounted for one out of every five antibiotic prescriptions to adults in that year. Overuse of antibiotics imposes unnecessary health care costs, places patients at risk for adverse drug reactions, and contributes to the emergence of antibiotic-resistant pathogens. Such resistance could cost as much as $7.5 billion a year in unnecessary costs (Phelps, 1989).
Hysterectomies. A study of the use of hysterectomies in seven managed care plans found that 16 percent were unnecessary (Bernstein, et al., 1993).
Tympanostomy Tubes. From 1991 to 1992, 23 percent of tympanostomy tube insertions for children with ear infections were found to be inappropriate (Kleinman, et al., 1994).
Misuse of Services
Errors in health care services cause missed or delayed diagnoses, unnecessary injuries, premature death, and often increased costs. Evidence of high rates of misuse of services include:
Hospital Injuries. In the landmark Harvard Medical Practice Study of hospitals in New York State, adverse events, where injuries result from medical management rather than underlying disease, occurred in 3.7 percent of all hospitalizations (Brennan, et al., 1991). Of these adverse events, nearly 14 resulted in death. Investigators attributed negligence as the cause of 27.6 percent of the adverse events and 51.3 percent of the deaths. Based on this study, Dr. Lucian Leape of Harvard School of Public Health has estimated that preventable errors in hospital care lead to 180,000 needless deaths each year (Leape, 1994).
Laboratory Tests. After rescreening, experts determined that anywhere from 10 to 30 percent of Pap smear test results were incorrectly classified as normal (Wilbur, 1997). These errors can result in missed or delayed diagnoses, sometimes meaning that patients have to go through more extensive and costly treatment.
Medication Errors. A study of two tertiary care hospitals found that among nonobstetrical patients that suffered an adverse reaction to a prescribed drug, an estimated 28 percent of these injuries were deemed preventable (Bates, et al., 1995). As a result, these patients spent more time in the hospital and health care costs increased. In fact, the authors of the study estimated that preventable adverse drug events would cost an additional $2.8 million for a 700-bed teaching hospital (Bates, et al., 1997). If the costs in this study were representative of and extrapolated to the Nation's acute care hospitals, these investigators estimated that the hospital costs of preventable adverse drug events would be $2 billion annually.
Ear Infections. One study demonstrates that the use of less expensive types of antibiotics for ear infections reduced the need for a second antibiotic course within 24 days of the initial therapy, was associated with a reduced rate of adverse drug reactions (ADRs), and led to similar or better outcomes than the more expensive alternatives (Berman, et al., 1997). Yet these more expensive alternatives are still commonly prescribed. If only half of the prescriptions for these antibiotics were written for the low-cost alternatives instead, the Colorado Medicaid program would have saved approximately 36 percent of its total costs for antibiotics for ear infections.
Variation in Services
There are significant geographic differences in practice that cannot be accounted for by differences in the health status of patients, available resources, patient preferences, or even clinical uncertainty. Such variation in services has contributed to disparities in mortality and morbidity.
Hospital Services. Hospital discharge rates and lengths of stay in the Northeast were 49 percent and 40 percent higher, respectively, than those in Western states (Graves and Gillum, 1997).
Cesarean Section Rates. Cesarean section rates in Washington State hospitals ranged from 0 percent to 43 percent (McKenzie and Stephenson, 1993).
Diabetes Care. Researchers found a twofold variation in routine care provided for diabetics (glycosylated hemoglobin measurement, eye exams, and total cholesterol measurement) across three States (Wiener, et al., 1995). The National Committee for Quality Assurance found a similar variation in the rate of eye exams routinely recommended for diabetics, with over 50 percent of diabetics receiving annual eye exams in New England managed care plans compared with 32.6 percent in plans in the South Central region of the country (NCQA, 1997).