Quality: Where We Have Been Where We Are Going

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QualityWhere We Have BeenWhere We Are Going
Paul D. Cleary, Ph.D.   Department of Heath Care
Policy 20th Anniversary Celebration April 29, 2008

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In the Beginning

• Pure FFS
• Predominantly solo practitioners and small groups
  for ambulatory care
• Not-for-profit, poorly run hospitals
• Only general concern about rising costs and
  proportion of GNP
• Little awareness of variability, quality, or
  errors Best care in the world!

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Traditional Approaches to Promote Quality

• Focus on individuals (e.g., physicians, nurses,
  administrators)
• Social-psychological-cognitive theories
• Education (e.g., MM conferences, CME, scientific
  literature)

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Findings of Early Health Services and Policy
Research

• The quality of health care is often less than
  optimal
• There are large regional and inter-organizational
  variations in quality of care
• There frequently are large racial, ethnic, age,
  and/or gender disparities in care

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Current Emphases forQuality Improvement

• Continued measure development and promotion
  Cochrane NQF
• Systems approaches to quality improvement
• Consumer choice
• Pay for performance
• Electronic medical records

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Many Strategies for Improving Quality

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Provider-Focused Strategies

• Training and certification
• Feedback
• Guidelines
• Decision support
• Rules and regulations
• Process and outcome incentives (e.g., HEDIS)

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Organization-Focused Strategies

• Feedback to organizations to facilitate quality
  improvement
• Regulation HIPAA, PROs/QIOs, bill of rights
• Pubic disclosure (e.g., PA, NY, MA)
• Management QA QI
• Accreditation (HEDIS Joint Commission)
• Contracting
• Structure incentives (Leapfrog)

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Market-Based Strategies

• Feedback to purchasers to facilitate choice and
  to stimulate pressure to improve quality
• Disclosure (e.g., PA, NY, MA, Medicare)
• Contracting
• Promoting types of management strategies (e.g.,
  HMOs)
• Competition (e.g., Medicare Advantage, Medicare
  Part D)

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Consumer-Focused Strategies

• Consumer education
• Information (e.g., web-based)
• Disclosure (e.g., PA, NY, MA, Medicare.gov, CAHPS)

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Provider Feedback

• Consistent with professional norms and
  expectations
• Many theoretical arguments to support such an
  approach
• Widespread frustration with lack of progress

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Guidelines

• Theoretically consistent with professional norms
• Consistent with principles of quality management
• Generally implemented poorly and seen as
  intrusive and cookie cutter medicine
• Cannot address complex decision making
• Widespread resistance and/or ignored

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Decision Support

• Consistent with professional norms and cognitive
  theories
• Consistent with principles of quality management
• More timely and synthesized data needed
• Good implementation requires more sophisticated
  and coordinated information systems
• Very expensive

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Training and Certification

• Continuous education (CME) ineffective
• New efforts to improve certification (ABMS-MOC)
  will have minimal impact for many years
  difficulty even establishing a floor

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Feedback to Purchasers

• Some organizations have taken a leadership role
  promoting quality of care
• Evidence suggests that purchasers decide
  primarily on price
• It is difficult for purchasers to monitor quality
• Markets too fragmented for concentrated effects

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Regulation

• Regulation is appealing and reassuring
• Regulation can be slow, inflexible,
  inappropriate, and ineffective
• Examples
• Obstetric care
• Medicare disclosure of financial incentives

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Accreditation

• Useful for achieving consensus on standards
• Little relationship to overall quality
• May facilitate disclosure and/or internal
  improvement

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Consumer Education

• Inherently good
• Too much information asymmetry to result in much
  quality improvement

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Managed Care

• Resisted by public and many clinicians
• Generally unsuccessful at improving efficiency or
  quality
• Current forms dramatically diluted from original
  concepts
• Failures probably cumulative effect of problems
  with specific strategies

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System Approaches to Quality Improvement

• Exciting models and dramatic success in industry
• Results to date in health care mixed

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Limits to Systems Approaches

• Contextual and inter-organizational issues often
  critical
• Fixing micro processes may not affect overall
  quality if other issues are not addressed (e.g.,
  leadership, professional attitudes)
• Need new models of care (e.g., true teams)

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Financial Incentives

• Revenue maximization is a high priority for
  individuals and organizations
• Incentives are most effective when motivation is
  a limiting factor and there is excess capacity
• Organizational incentives can target
  infrastructure deficits
• Any incentives are limited by coherence and
  awareness

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Problem with Many MechanismsLack of Coherent
Structures
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Disclosure

• Great interest in transparency and
  accountability, but
• Information must be valid
• Information must be salient to decisions
• Information must be presented in a useful format
• Information must be read and understood
• Information must influence decisions or be
  perceived as influencing decisions
• A sufficient number of providers must participate
• Poor providers must fail and/or improve in
  response
• Sunshine effect may be more important than
  consumer choice

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The Current Situation

• Dramatic improvements in research methods and
  commitment
• Many care improvements
• Improvements have been slower than almost
  everyone wanted and expected
• Systems, infrastructure, policy, science, data,
  and care continue to be fragmented and
  uncoordinated
• Medical care continues to be craft work
• Physicians, purchasers, and consumers all
  frustrated

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What is needed for a medicalindustrial
revolution?

• More coordinated, timely data on treatments and
  for decision support
• Information infrastructure
• Simplified, integrated structures for purchasers,
  regulators, and providers
• Support and incentives for infrastructure
• New models of care coordination that leverage
  physician expertise
• New manpower policies

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Most Dramatic Changes in Health CareSystem-Wide
Change

• 1965 - Medicaid and Medicare
• 1980s - Health Maintenance Organizations
• 1990s - VA transformation
• 2000s - CMS focus on quality (e.g., never events,
  value purchasing)

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Conclusion

• Closing the chasm between what is done and what
  is possible will require better use of existing
  data and bold new thinking about data standards,
  systems, and providers
• More consolidation or coordination of oversight
  and improvement functions necessary