Improving the Quality of Health Care:
The Federal Government Must Play a Vital Role

By on

A Call for Federal Legislation in 1999
The National Coalition on Health Care
March 1999Introduction
I. Update the mission and increase funding of the Agency for Health Care Policy and Research (AHCPR).
II. Launch a test of methods to identify medical errors and enhance patient safety.
III. Pass a law to protect the privacy and confidentiality of medical records and promote the computerization of medical records.


An abundance of research now shows that there are serious problems with the quality of medical care in the United States.

In the past two years, four major reports ñ two from blue ribbon panels ñ have concluded that there are large gaps between the care Americans should receive and the care they do receive. In addition the reports concurred that the health system is plagued with overuse, underuse and misuse of health care services.1

Studies show, for example, that 10% to 20% of many common operations and surgical procedures are performed unnecessarily or inappropriately. Some 20 million prescriptions for antibiotics are written every year for people who have colds ñ a useless treatment since antibiotics do not kill cold viruses. At the same time, many effective treatments and preventive measures ñ such as childhood immunizations, flu shots, mammograms, and heart attack medicines ñ are underused. And medicine is practiced so differently around the country that experts now believe much of the care people get is driven by custom, habit and personal preference ñ not science.

Errors in medicine are a hidden epidemic. A landmark 1991 study estimated that 1 million patients are injured every year as a result of medical errors and mistakes. As many as 180,000 deaths each year may be linked to such errors.2 The vast majority of errors occur not because health professionals are incompetent or uncaring, but because they work in flawed and complex systems which too often fail.

Despite the magnitude of these problems, our nation has done too little to address them. We believe it is time to mount a national effort to improve the quality of health care. Such an effort must take place in both the private and public sectors. The federal government has a vital role to play in leading and supporting such as effort.

The United States is poised to enter a new era of medical discovery and progress in the 21st Century. Congress and the administration have embraced that reality by pledging a 50% increase in funding of the National Institutes of Health (NIH) over the next five years. It should also commit to building on that investment by expanding support for research that fosters the appropriate and swift use of the discoveries our biomedical researchers make. Indeed, a portion of the increased investment in NIH will be squandered if we can not assure that the actual delivery of care will keep pace with medical advances.

We would submit as well that Congress has a fiduciary (as well as moral) responsibility to assure that optimal medical care is delivered in the United States. The federal government pays 37% of the nationís $1.1 trillion health care bill. It administers the nationís largest public health insurance program ñ Medicare. And it is the nationís largest employer, providing health insurance to nine million federal workers and their dependents.

The principle federal agency responsible for research to improve the quality care is the Agency for Health Care Policy and Research. Created in 1989, the agency has helped foster a new era in health care quality assessment and improvement. The research it has supported has led to major advances in understanding treatment for dozens of diseases and illnesses. The agency has also put renewed focus on preventive care and led the effort to foster the emerging field of evidence-based medicine. But for all its good works, the agency has been severely hampered by a lack of resources. Its current budget is $171 million. That represents a fraction of 1% (0.016% to be precise) of national health care spending. Similarly, the agencyís budget is 1.6% of NIHís. The amount is inadequate when the potential for the agencyís activities and research is carefully assessed. The Coalition believes the agencyís mission should be expanded, its role strengthened, its name changed, and its funding sharply increased. (See below.)

The anticipated debate this year over managed care regulation and a patientsí “bill of rights” is further justification for enhancing our nationís capacity to determine what works best in medicine. At its core, the bill of rights debate is about how we should define, and who should define, what is “medically necessary” care. Should it be health professionals such as doctors and nurses or should it be insurance and managed care administrators? The debate arises in the first place because there is disagreement over what in fact is medically necessary for any given patient or group of patients. But as we get better over time at defining what appropriate care is and nurturing the practice of evidence-based medicine, there will be fewer disagreements and more room for health professionals and health insurance plans to work together to improve the quality of care.

Finally, Congress and the nation face a tremendous challenge restraining the growth in health care costs as the baby boom generation ages and as new technologies emerge. Research powerfully suggests that improving the quality of care ñ maximizing the use of the most appropriate care and eliminating what does not work ñ is the single most effective way to control health care costs over the long term. Costs will not be controlled over the long haul by cutting payments to health professionals or facilities, by designing new insurance systems, by granting consumers rights and protections (however important), or by shifting costs to consumers. By definition, only a health system which delivers optimal evidence-based care to the maximum number of people can cost the “right” amount.

Congress has a window of opportunity in 1999 to begin putting our health care system on a new footing. As they address the bill of rights and Medicareís future, lawmakers should not fail to recognize the critical importance of taking action to improve the quality of care. The science and tools exist to do this now. What is needed is the vision, the commitment of appropriate resources and the political will.


The National Coalition on Health Care recommends that Congress take the following steps this year to lay the foundation for a national effort over the next decade to improve the quality of health care and enhance patient safety. These measures are consistent with the findings and recommendations of a panel of experts convened by the Institute of Medicine (The IOM National Roundtable on Health Care Quality) and the Presidentís Advisory Commission on Consumer Protection and Quality in the Health Care Industry.

I. Update the mission and increase funding of the Agency for Health Care Policy and Research (AHCPR).

The agencyís core mission to improve the quality of medical care and health care services should be significantly strengthened. The agency would retain its research and grant-making focus to foster knowledge and private sector initiatives in quality improvement. But it should be given larger purview over health care improvement activities in the federal governmentís health programs. In addition, the agencyís role as a disseminator of information on health quality to health professionals, payers, and the public needs to be significantly enhanced.

The agency should continue to have no regulatory authority. However, the scope and responsibility of the agencyís current advisory council ñ the National Advisory Council for Health Care Policy, Research, and Evaluation, which we would rename the National Advisory Council for Health Care Quality and Improvement ñ should be expanded. The Council, which is currently comprised of 18 experts from the private sector and seven government officials, would be newly charged with identifying national aims and goals for health care quality improvement. These would take a form similar to the Healthy People 2000 and Healthy People 2005 projects sponsored by the Department of Health and Human Services. The Council would issue periodic reports tracking the nationís progress in meeting the goals it sets.

The Coalition recommends that the agencyís budget be doubled over the next three fiscal years, rising to $342,000,000 in fiscal 2002. The agencyís name should be changed. We suggest: The Agency for Health Care Research and Quality (AHCRQ). The agencyís central missions should be modified to emphasize the following:

  • Help set quality improvement initiatives for all federal health programs.
  • Promote and advance the concept of evidence-based medical care.
  • Identify “best practices” and innovations in health care delivery and clinical medicine, working with other federal agencies and the private sector to accelerate the spread of best practices to health professionals and facilities nationwide.
  • Initiate a program to identify best medical practices internationally and foster their adoption in the U.S. as appropriate. Work with other nations to jointly identify cost-effective, safe and exemplary care.
  • Develop a state-of-the-art medical technology assessment program. Make grants to private sector groups and contractors to perform assessments to evaluate the cost-effectiveness of medical technologies and procedures.
  • Launch a new program to research the cause of medical errors. Promote patient safety through research and dissemination of information on safe medical practice.
  • Launch a program to identify unnecessary care and medical treatments, procedures and surgeries that are either overused or under-used. Promote their more appropriate use.
  • Foster and evaluate information systems in health care that improve care but do not compromise patient confidentiality.
  • Expand the guideline clearinghouse (currently a public/private partnership with the American Association of Health Plans and the American Medical Association).
  • Launch a new program to evaluate the quality of medical care received by vulnerable populations (including the disabled).

II. Launch a test of methods to identify medical errors and enhance patient safety.

Congress should specifically authorize and fund a demonstration project that would test several methods of medical error reporting and analysis. The need for such an initiative is now broadly supported in the medical community. The consensus is that it could yield valuable data and information on weaknesses in complex health care systems that produce errors or compromise patient safety.

The new program should be overseen by AHCRQ. Technical assistance would come from other federal agencies. (e.g. the FAA and NASA which operate the much praised Aviation Safety Reporting System, ASRS). An expert public/private panel would be tasked to spend a year designing the demonstration project. This panel would then oversee initial implementation and start-up, most likely by a private-sector contractor.

Error reporting is a highly complex because of the legal issues involved. Health providers live in fear they will be sued for malpractice or otherwise penalized if they report errors, mistakes, or lapses in judgement. Most experts agree that federal and state medical malpractice laws would eventually have to be changed to give legal protection to individuals reporting medical errors. But we believe that tests of reporting systems can and should proceed even in the absence of such changes in the law.

III. Pass a law to protect the privacy and confidentiality of medical records and promote the computerization of medical records

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that Congress pass such a law by August 1999. The Coalition urges Congress to meet that deadline. There is a broad consensus in the health care industry that the computerization of medical records is vital to improving the quality of care ñ through the timely sharing of data among providers on the care of individual patients and by enhancing public health knowledge and research. But such progress is hampered now by legitimate concerns that the privacy of medical information and records is currently compromised. Clear rules and standards will kill two very big birds with one giant stone: it will (and should) protect consumers and it will prescribe the proper, legal use of patient specific data for research, quality improvement and public health purposes.


  1. Quality First: Better Health Care for All Americans, Report to the President by the Advisory Commission on Consumer Protection and Quality in the Health Care Industry (March 1998); Mark R. Chassin et al, The Urgent Need to Improve Health Care Quality, Report of the Institute of Medicine National Roundtable on Health Care Quality, Journal of the American Medical Association (September 16, 1998); Mark A. Shuster, Elizabeth A. McGlynn, and Robert H. Brook, Why the Quality of U.S. Health Care Must Be Improved, A RAND report funded and issued by the National Coalition on Health Care (October 1997); and Donald M. Berwick, As Good As It Should Get: Making Health Care Better in the New Millenium; A report funded and issued by the National Coalition on Health Care, (September 1998)
  2. Lucian L. Leape, T.A. Brennan, et al, Incidence of Adverse Events and Negligence in Hospitalized Patients and The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study, New England Journal of Medicine, (1991: Vol. 324, pages 370-384). See also: Lucian L. Leape, Error in Medicine, Journal of the American Medical Association (December 21, 1994, Vol. 272, No.23)