QUALITY OF CARE IN THE UNITED STATES: MYTHS AND REALITIES
Aside from the newspaper accounts on quality of care problems in many managed care programs, there remains serious and fundamental problems with the quality of care in the United States, and those problems are substantial and widespread. Effective improvement of quality of care must begin with a focus on the real magnitude and scope of the problem.
MYTH 1 ñ Health care providers agree on the care that patients should receive for many medical conditions.
REALITY – 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. 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 affects 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 then 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 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.
MYTH 2 ñ All providers are required to follow clinical guidelines when treating patients.
REALITY – 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 national database on quality. This makes it very difficult for health professionals to practice as well as they like or as well as patients would like to see care rendered.
MYTH 3 ñ Patients can obtain reliable information on quality in order to make informed decisions about treatment and provider choices.
REALITYñ Unfortunately, timely and credible information on what does and does not work in medical care and in different delivery settings does not exist. 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.
MYTH 4 ñ Providers are only delivering necessary services to patients and mechanisms are in place to assure this process.
REALITY – A great deal of inappropriate care is being provided and results in a substantial amount of harm. And 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 120,000 each year, are considered preventable. The Harvard team concluded that medical injury and malpractice constitute the nationís “hidden epidemic.”
MYTH 5 ñ We have in place a comprehensive quality assurance system in the United States.
REALITY — 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.Major inadequacies continue to remain in our quality assurance and measurement systems.
MYTH 6 ñ There is a great deal of public information on quality of care.
REALITY – There are some quality measurement programs in place but they are slowly evolving but remain fragmented, which include the development of quality report cards that consumers use to compare health plans and providers. However, we are still not capturing 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.
MYTH 7 ñ The private sector and the market can by itself provide the necessary quality of care information to all the purchasers of health care.
REALITY — 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.
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.