Authenticating Healthcare Quality

Each year, the ten journals of the American Medical Association designate one issue for coordinated publication on a central theme; for 1997, the topic chosen was quality of care. Writing in the November 19 edition of the Journal of the American Medical Association, editor George D. Lundberg, M.D., and John E. Wennberg, M.D., issued a call to action to their fellow physicians:

Many articles published in the leading primary-source, peer-reviewed medical journals provide information of such overriding importance as to demand action to improve patient care and protect the health of the public. Some new information even suggests urgent action. Yet the traditional response to such publication has been for researchers, physicians, and other readers to receive such information and to act (or not to act) on it as they wish or choose. In some instances, this has worked well; in others, not so well. Often response has been slow and uneven…. A regular organized response to the identification of such clear problems with clear solutions could serve the health of the public to a greater extent than simply publishing and distributing such information and waiting to see what happens.

The editorial sounds two major themes of today’s healthcare policy discussions: the concern for improving quality and the quest for an information framework to support more informed decisions—assisting not only consumers and purchasers but clinicians and plan managers as well. Increasingly, quality and information issues are raised from a consumer perspective, as when the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry included in its November 1997 “Consumer Bill of Rights and Responsibilities” the following language: “Consumers have the right to receive accurate, easily understood information and some require assistance in making informed health care decisions about their health plans, facilities, and providers.” Indeed, the commission owes its existence to public concerns about the quality of medical care being delivered in the United States.

Media attention to these concerns has frequently emphasized the stories of those who feel they have been denied proper care by an HMO or other managed care organization. Allegations are made that managed-care cost-cutters are withholding care doctors believe to be medically necessary. Implicit in these lamentations is the idea that a return to total physician autonomy would save lives.

But, as Michael L. Millenson writes in Beyond the Managed Care Backlash,¹

The myth of a lost “Golden Age” of medicine before the advent of managed care should be rejected. Marcus Welby isn’t just dead; he never existed in the first place. False nostalgia notwithstanding, the old guild structure of professional self-policing demonstrably failed to protect patients from ineffective, inappropriate, and even dangerous care.

In Congress and in state capitals around the country, much of the health-related legislation introduced in the last several years has been aimed at reining in the power of managed care. But policymakers may be in danger of turning all their firepower on managed care when the larger public health concern is ensuring quality of care across the entire spectrum of U.S. health care.

This Forum session, intended as an overview, will take a broad look at issues of quality and accountability. Those concerned with quality often cite difficulty in getting questions answered, limited access to specialists, fear that sickness will lead to loss of coverage, and denial of coverage for treatments deemed experimental. Rarely is actual clinical evidence the basis of worry, though this may be in large part because people do not have sufficient data on which to judge clinical competence. What is the appropriate basis on which to judge quality? What data elements would enable measurement that is accurate, reliable, and understandable? Who should collect this information, and what tools do they need? How should the information be communicated?

Information is a necessary step toward accountability. But who is to be held accountable for delivering quality care? And how? Lundberg and Wennberg suggest the medical profession itself needs to take more active responsibility. Millenson sees signs of progress. In his recently published book, Demanding Medical Excellence,² he cites evidence that, “for all the confusion, the transition toward genuine accountability in health care is inexorably underway…. Managed care does not have to doom our medical system to austerity and parsimony.”

Millenson acknowledges, however, that achieving the ideal of a responsive and accountable system

demands much more than digitizing data. Plugging numbers into a computer is an easy trick. Changing people’s expectations and behavior is something else again. True stewardship requires a relationship among doctors, patients, health plans, and employers that rests on a foundation of shared information.

Discussions of health system change have long been marked by a splintering among different components of the system. Doctors, hospitals, insurance companies, and HMOs have all had their turns as the villain, accused of indifference and greed. While finger-pointing has not ceased, many health system participants would rather turn their energies to forming effective partnerships and working toward an equitable division of responsibilities.

This is not a clear-cut process. While achieving consistently high-quality health care certainly benefits all, developing workable measurement systems requires sorting out divergent priorities and providing for standardization and coordination on a national as well as local basis. Quality-measurement projects are underway in both the public and private sectors, but none has emerged as an answer acceptable to all.

This Forum session will highlight a series of questions that must be addressed as health care players formulate reasonable expectations for the short term and a plan for long-term nurturance of quality.

• How can the wide-ranging and sometimes conflicting interests, needs and priorities of different actors within the health care industry be balanced to produce a satisfactory framework for identifying and evaluating quality?
• How can different approaches to or preferred methods for assuring health care accountability best be structured or dovetailed?
• What are different sectors of the industry willing to invest for information on quality and what do they expect to get for their investment?
• What is the state of the art in quality measurement, where does it fall short and how best may it be advanced?
• What technical obstacles need to be overcome so that hospitals, health plans, physicians and others can supply needed information on quality?
• Who should provide leadership in discussing and resolving issues related to health care quality and accountability?
• Should quality measures be legally enforceable? If voluntary, what steps can be taken to promote compliance?

In the accompanying background document, Mary Darby, a consultant to NHPF, provides some important history and context for these questions. The material will be alluded to in this Forum session and others to follow.

Michael L. Millenson, a member of the Health Care and Group Benefits practice of William M. Mercer, Inc., is nationally recognized for his examination of issues affecting the cost and quality of medical care. His recently published book, Demanding Medical Excellence, is the first examination of quality of care issues for the general public. Millenson worked with the Jackson Hole Group during the creation of the Foundation for Accountability. Before that, as a reporter for the Chicago Tribune, he was nominated for a Pulitzer Prize in 1987, 1991, and 1993.

George D. Lundberg, M.D., since 1982 has been with the American Medical Association, where he is editor-in-chief, scientific information and multimedia (39 medical journals, American Medical News, and various Internet products) and the editor of the Journal of the American Medical Association. His earlier experience includes working in tropical medicine in Central America and forensic medicine in New York, Sweden, and England, as well as serving as professor of pathology and associate director of laboratories at the Los Angeles County/USC Medical Center for ten years. He is a past president of the American Society of Clinical Pathologists and holds academic appointments as a professor at Northwestern and Harvard.

Endnotes

1

Michael L. Millenson, “Beyond the Managed Care Backlash: Medicine in the Information Age,” Health Priorities Project Policy Report No. 1, Progressive Policy Institute, Washington, D.C., July 1997.

2

Michael L. Millenson, Demanding Medical Excellence: Doctors and Accountability in the Information Age (Chicago: University of Chicago Press, 1997); written under an Investigator in Health Policy award from the Robert Wood Johnson Foundation.

A discussion featuring

• Michael L. Millenson
  Senior Analyst
  Health Care and Group Benefits Practice
  William L. Mercer, Inc.
• George D. Lundberg, M.D.
  Editor
  Journal of the American Medical Association

NHPF is a nonpartisan education and information exchange for federal health policymakers.