NCHC Writer
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WASHINGTON, D.C., 11/19/97

      I have been asked to share our Coalition’s views on the state of health care quality in America. As the nation’s largest and most broadly representative health alliance, we have long been concerned with this issue. This concern is shared by all our 93 members who represent or employ over one hundred million Americans. We are non-partisan. Presidents Carter and Ford honor us as co-chairs and Governor Bob Ray, a Republican, and Congressman Paul Rogers, a Democrat, lead our effort.

      I believe you have reason to be proud of your work in developing a Bill of Rights, but much more now needs to be done to see those rights are assured and to deal with the underlying causes of the quality problem and with the interrelated nature of the two other major health care problems we face.

      Let me explain. Last month, our Coalition released studies on the nation’s three major health care problems. They showed that the health care crisis, acknowledged by both Presidential candidates in 1992 is not only still with us, but is, in fact, growing worse and that the problems of quality, rising costs, and coverage are interrelated and therefore cannot be dealt with in isolation from each other.

      In light of this we have long considered quality a central problem and a cause for deep concern. The causes of our concern have been described in our Quality report and by your many witnesses and include massive variations in medical care, millions of errors and major gaps in our knowledge and databases. You have learned that much of our technology has been adopted without adequate evaluation and that evidence to justify treatment of even the most common medical and surgical conditions is often questionable. Health professionals are working in flawed systems with inadequate data and quality controls. Studies by Harvard have concluded that medical negligence and malpractice constitute the nation’s “hidden epidemic” and because of these deficiencies and the resultant overuse, underuse and misuse of our technology, hundreds of billions of dollars are wasted, millions are injured and tens of thousands die unnecessarily each year. Quality experts say that no other industry would be allowed to operate even a day with a quality and safety record such as this. The quality problems existed long before the advent of managed care, and are found even in the nation’s pre-eminent institutions.

      Despite the seriousness of these problems, our nation has no integrated and adequate system for assessing or assuring quality. Currently there is no credible national quality database nor do we have in place the necessary technology and standard-setting mechanisms, which makes it very difficult for health professionals to practice as well as they would like or as well as the American people would like.

      What steps are needed to bring about major improvements in the quality of our care? First, we believe we have to recognize that neither the market, or managed care or voluntary action alone nor the private sector alone will be able to correct problems of this magnitude. These problems are so large and complex that we need a major, national commitment– a quality “moonshot” if you will, with the resources necessary to establish priorities and goals, to fund necessary research, to carry out the necessary studies, and develop necessary systems, and data. We need far more of what excellent entities such as the Agency for Health Care Policy and Research and some in the private sector have begun.

      Second, the nation needs to proceed in a “no-fault” manner to establish a credible and publicly accountable quality measurement and assurance system and a structure and process that will bring together the strengths of the public and the private sectors, with the resources and authority necessary to do the job. We will need an arbiter and a rule setter. More detailed suggestions are contained in our Rand study and in our formal statement.

      In addressing our quality problems, we must constantly be aware of the interrelationships between the cost, coverage and quality problems. Costs are now rising at twice the rate of inflation and will increase 500 billion dollars in just the next five years. Today’s 1 trillion-dollar system will double in cost to 2 trillion dollars in the next decade. A major factor increasing costs is poor quality and the resultant extensive waste and poor outcomes.

      Largely due to rising costs, our safety nets, including the employment-based health insurance system, are deteriorating, and the number of uninsured is increasing at a rate of over 1 million each year. With present trends we soon will have 80 million of our fellow citizens with no health insurance or with inadequate insurance. We know that in the absence of insurance coverage, or cross subsidies it is increasingly difficult to get needed care. The result is that health outcomes and quality suffer. In fact, Professor Robert Brook, M.D., one of the RAND authors of the Coalition’s quality study asserts that other than aging, the biggest risk factor associated with a poor outcome or death is the lack of health insurance. Whether or not you receive needed care (determined largely by whether you have insurance) can determine whether you live or die. So, the quality, cost and coverage problems are intertwined and cannot be successfully addressed independently.

      Therefore, in our view there is no more fundamental consumer right than to be assured that care is evidence-based, effectively delivered and available to all who need it, when they need it. If not coupled with these elements, a Bill of Rights will not fulfill its promises or meet the public’s need. In addition, costs will not be contained and the vicious cycle of increasing costs and cost shifting, decreasing coverage and resultant poor quality will continue. Without universal coverage meaningful competition will be difficult to achieve. Our health system’s problems cannot be corrected without universal coverage coupled with improved quality. These are the bedrocks on which a better system must rest.

      We believe your Commission can make a lasting contribution to the public good by insisting on and incorporating these fundamental elements as key elements of the next phase of your effort. We plan to do all we can to help make that happen. Thank you.