Key Findings on Quality of Care in the United States

      The RAND report and other studies present data and evidence which provide a framework for understanding the extent of the quality problems in the United States.

Numerous studies point out that the quality of care in the United States varies widely among providers and regions.

• There are major gaps in our knowledge base which contribute to medical uncertainty. Much of our medical technology has been adopted and widely utilized without adequate evaluation. The evidence to justify treatment of even the most common medical and surgical conditions is often questionable. This includes such common conditions as prostate cancer and low back pain, which affect millions of people.
• Medical uncertainty leads to enormous regional variations in health care with no evidence that people in regions with access to more care have better outcomes than people in regions with less care.
• Such huge variation is scientifically indefensible. The literature is replete with studies that show that physicians disagree with each other and even among themselves a high proportion of the time. Often no one knows who is right. This is not to infer that health professionals are trying to harm people; they are not. The fact is that they work in flawed systems, and that these flaws have to be acknowledged and fixed in a no-fault environment.

Care provided to patients frequently does not meet professional standards (and in many cases providers do not have authoritative clinical guidelines to follow because outcomes information has not been collected or standards developed).

• There is no credible national database on quality, or a national technology assessment or standard setting mechanism. This makes it very difficult for health professionals to practice as well as they would like or as well as patients would like to see care rendered.
• Without timely and credible information on what does and does not work in medical care and in different delivery settings, consumers and providers have difficulty knowing what treatments are effective, the benefits and risks of alternative treatments, and the right providers to go to in each situation. The perception is that patients can obtain this information, but in many cases the information is incomplete, not easily accessible, or simply not available.

A great deal of inappropriate care is being provided and results in a substantial amount of harm.

Since our quality control assessment and assurance mechanisms are so rudimentary, treatment mistakes and errors are much more common, costly, and harmful than generally realized.There are distressingly high error rates reported in a wide range of medical practices with serious, sometimes fatal consequences. For example, autopsy studies show high rates (35 to 40 percent) of missed diagnoses, often resulting in death. Tragedies such as these are not isolated events. The “Harvard Medical Practice Study in the State of New York” has demonstrated this dramatically.If the New York rates can be extrapolated to the country as a whole, then the Harvard researchers estimate that over a million patients are injured in our hospitals every year, and approximately 180,000 people die each year as a result of medically induced injury or negligence. One-half of these deaths, or 90,000 each year, are considered preventable. The Harvard team concluded that medical injury and malpractice constitute the nation’s “hidden epidemic.”

Major inadequacies continue to remain in our quality assurance and measurement systems.

• Many believe that we have a comprehensive system in place to identify quality problems and assure quality. Unfortunately, we only have a patchwork of mechanisms, with little uniformity, breadth, or ability to produce rapid results. And the measurements do not yet cover many of the providers of care in the U.S.
• These measurement programs that are slowly evolving include the development of report cards that consumers can use to compare health care plans and providers; larger systems, such as the National Committee on Quality Assurance that accredits health plans; and employer initiatives like that of the Pacific Business Group on Health, which conducts a variety of programs to measure and improve quality.
• However, we do not capture information on conditions, treatments, or outcomes from many physicians, hospitals, health care plans or insurers. Much of the information remains proprietary and is not available to the public. We have no ongoing quality measurement system that allows rapid assessments of changes in the health care marketplace. For example, managed care is changing so rapidly that most of the studies on quality are out of date.
• The bottom line for the nation (and specifically for government and private sector programs that finance health care) is that if useless and potentially harmful care were eliminated, there could be huge savings in terms of human and financial costs. Also, if timely and credible studies were available, the health of the nation could be improved.

Where do we go from here to address the issues identified in this and other reports?

A Vision for Quality Accountability in Health Care

• Inform consumers and purchasers about the care they should receive.
• Help physicians and patients make treatment and referral decisions.
• Help clinicians and health plans continuously improve their care.
• Determine the impact of new public policies and delivery systems.
• Provide clinical input to financial decision making processes.

A comprehensive quality measurement system is necessary to provide the multiple participants in the health care system with the information they need to make sure that the system provides and continues to provide high quality care.

Second, we need to be able to measure care across different sites of care (ambulatory, inpatient, etc.) and types of care (preventive, diagnostic, etc.).

Third, we need to develop both internal and external models to help clinicians focus efforts to improve quality and to make quality information available to consumers and large purchasers.

Fourth, employers and other payers need to require quality monitoring by the health plans they select.

How can we improve quality when we have so little information and our methods for measuring quality are inadequately understood and utilized?

Elements of a High-Quality Health Care Organization

Based on the RAND study, the Coalition concurs that there are critical elements for an effective quality monitoring and assessment system that organizations in the health care delivery business must adopt:

• The assessment methods should be population-based so they take into account everyone who could benefit from care regardless of whether services are used.
• The methods should cover all aspects of a health care delivery system because care may vary within an organization and because consumers may be concerned more with some forms of care than others.
• The methods should control for demographic and other differences in enrolled populations and for factors outside of the control of the health care delivery system that influence outcomes of care.
• The measurement system must be flexible and adaptable as new treatment strategies are developed.
• The organization needs to use diverse measures (structural, process and outcomes) which will provide different perspectives on care.
• Organizations must develop computer systems that collect and merge key pieces of clinical information which will facilitate quality measurement.
• The findings of an organization’s quality measurement system must be presented in formats that can be understood by all constituents.

Quality in the Larger Health Care System

• To support these efforts, the marketplace must come up with a standard set of measures that cover the interests of various constituencies.
• It is doubtful that the market alone can ensure and improve the quality of health care on a system wide basis. Government and the private sector both have an important role to play in creating a quality measurement and reporting infrastructure.
• At the national level, we need to arrive at a consensus regarding priorities for measurement. This is critically important because current measurement efforts are being driven, to some extent, by our capability to measure in certain areas, as opposed to recognized needs for certain types of measures.
• The Coalition believes that a national, comprehensive and systematic strategy for routine monitoring and reporting on quality as well as the information systems needed to support such activities are essential, if we are to preserve the best of the American health care system, while striving to improve the efficiency with which high quality services are provided.

Full copies of “Why the Quality of U.S. Health Care Must Be Improved” are available by contacting the National Coalition on Health Care at (202) 637-6830.

Press Release: The State of Health Care Quality in America: A Report to the Nation