American College of Physicians: Internal Medicine — Doctors for Adults ®

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From the President

Measuring quality of care: new focus on a difficult task

From the February 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Christine K. Cassel, FACP

Now that the costs of health care, at least as reflected in the costs paid by employers and public payers, seem to be under control, many fear that we have no consistent way to evaluate the quality of care. The momentum is such that there are signs that in the coming year, the federal government will get more involved in evaluating the quality of health care.

It's an onerous task. Quality is difficult to document and measure because it requires an extensive level of data collection and innovative research strategies. To date, the marketplace has primarily relied on patient satisfaction surveys to measure quality of care, with health plans and hospitals looking to patient surveys as marketing tools. The competitive marketplace has taught us important lessons about the value of "customers" and how they view our services. And while these surveys can yield important details such as patient attitudes about waiting times, amenities and respectful treatment, quality experts are the first to acknowledge that patient satisfaction may not be directly related to quality of care.

Clinical expertise, effectiveness and patient outcomes, however, are harder to measure. A group of large employers has been working with the National Committee for Quality Assurance (NCQA) to develop the Healthplan Employer Data and Information Set (HEDIS) measures, which are currently being used to certify health plans. In addition, HCFA is developing a new kind of HEDIS measure to evaluate Medicare managed care plans.

Geriatrics experts have argued that while measuring preventive care services such as influenza vaccines and mammography rates is important, it will never tell the whole story about quality of care for older patients with multiple chronic illnesses. As a result, they urge that more complex measures such as functional outcomes be included. While these kinds of studies add to the expense of data collection and the complexity of quality measures, in the end they will clearly be beneficial. You will know how well patients are doing at discharge and months later.

Despite these developments in measuring quality, many patients remain worried about the quality of care they receive, and there is new interest in having the government regulate some aspects of health care. An example is the recent flurry of legislative activity to allow patients to remain in the hospital for two days after normal deliveries and mastectomies.

In a recent visit to Capitol Hill, several members of Congress asked me about ACP's position on the two-day requirement for mastectomies. My answer was that this is a matter to be decided between the doctor and the patient. The College firmly believes that the legislature is not the way to solve length-of-stay issues, and that how long a patient stays in the hospital for an illness or procedure is an individual matter that requires clinical expertise and patient input.

But given current circumstances, the public is more concerned than ever about quality of health care. A recent survey by the National Coalition on Health Care, an organization that represents health care providers, health care purchasers, labor unions, corporations and patient groups, demonstrated the public's shrinking confidence in the quality of American health care. Approximately 80% of respondents believe that the average person cannot afford quality health care. A majority of respondents said they felt that attempts to cut costs have compromised the quality of health care, and that hospitals are full of mistakes, incompetent people and systems that don't work. This alarmist reaction may be based on a few personal experiences and on media reporting, but we need to take it seriously. (ACP joined other health care leaders at a press conference in Washington to announce the results of this poll.)

Interesting, the survey also found that 70% of all respondents said their out-of-pocket health care costs have increased, while their health care coverage has decreased. This is an important observation which may explain why costs to the employers on the national level seems to have declined.

But perhaps the strongest message from the survey was respondents' perceived need for the government to take a role in ensuring the quality of health care. Any government role must go farther than simply passing legislation requiring two-day hospitalizations for normal deliveries and mastectomies. Most thoughtful legislators realized this. The College testified at a Senate hearing co-sponsored by Senators Bill Frist (R-Tenn.) and Joseph I. Lieberman (D-Conn.) in December exploring ways for the government to maintain, regulate and measure quality of care. In addition, President Clinton has announced that he will appoint a commission on quality of care to make recommendations in this area.

As the College focuses on quality of care, its leaders emphasize that the people who are at greatest risk for poor quality of care are the uninsured and the underinsured. This has now been documented by numerous studies, several in the last year, that have shown that uninsured and underinsured patients do in fact have worse outcomes as well as less access to primary and preventive care. Thus, as we look at ways to measure, document, improve and maintain quality of care, we must not lose sight of individuals who do not fall under our measurement umbrella because they are outside the system.

To take quality of care seriously is a tall order, but we owe ourselves and our nation nothing less.

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