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


Examining the quality ‘chasm’ in health care

From the May 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

When the Institute of Medicine first began examining the difference between evidence-based “best practices” and actual therapies, the group’s leaders initially talked about a gap in physician behaviors. They quickly realized, however, that the problem was much bigger.

Kenneth I. Shine, MACP, president of the Institute of Medicine (IOM), told a meeting of the College’s Board of Governors before Annual Session that the IOM discovered 30% to 50% of all patients don’t get therapeutic interventions that have been proven effective, from treatments for depression to beta blockers. “We realized that the word ‘gap’ was inadequate,” he said.

The IOM’s most recent report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” concludes that the health care system needs fundamental change if quality measurement and improvement are ever going to take place. “Trying harder will not work, and that’s true of both systems and individuals,” Dr. Shine told the College’s Governors. “In the absence of improved care systems and thinking about quality in different ways, we will not get the kinds of improvement required.”

Before the nation is able to protect patient safety and improve the quality of health care, Dr. Shine said, the following four areas of health care will have to change:

  • Payment policies. Dr. Shine pointed out that current payment policies actually discourage quality improvements. Physicians who start communicating with diabetic patients by e-mail—which Dr. Shine said can lead to better management of the disease—are typically not reimbursed.

    In hospitals, he said, “The irony is that if we cause renal failure with inappropriate antibiotic use, the hospital makes more money because it can use more complex DRGs.”

  • Chronic care management. Dr. Shine pointed out that 20 chronic care conditions now account for almost 80% of all health care expenditures. While evidence shows that a multidisciplinary team approach greatly improves the management of most chronic conditions, chronic care continues to be plagued by poor health care communications among physicians and hospitals, as well as inadequate technological infrastructures.

  • Information technology. Evidence shows that information technology greatly enhances quality initiatives and error reduction. Yet Dr. Shine claimed that information technology in health care is grossly underfunded. As a result, the industry lacks widely used data standards.

  • Medical knowledge. Dr. Shine pointed out that thousands of new medical devices are approved each year, while federally-funded research and the Human Genome Project continue to dramatically expand scientific knowledge. The growing knowledge base makes it even more imperative to be able to measure quality and implement quality initiatives.

Dr. Shine said that the IOM is asking Congress to establish a $1 billion innovation fund for the Agency for Healthcare Research Quality (AHRQ) to seed quality improvement projects and identify quality improvement models. The IOM also wants the government to further invest in technology and a new information infrastructure for health care delivery.

Dr. Shine said he is optimistic that payment models may start to change. He explained that there is a growing commitment from The Leapfrog Group—a consortium of more than 70 large employers—to reward improved quality with higher reimbursements and to financially penalize low quality health care. He said that the group’s efforts will be a major influence in removing barriers to paying for quality.

Physicians will then be able to directly benefit from quality improvements through better reimbursements and market share, Dr. Shine predicted. But he warned that physicians will have to change their own culture and what he called physicians’ “expectations of infalliability,” which all too often keep them from improving systems in which errors and poor quality medicine occur.

“We have focused on the concept of lifelong learning,” Dr. Shine told the Governors. “I would argue that we need to adopt the concept of lifelong change.”

By improving quality in both individual behavior and health care systems, physicians will begin to be able to tackle two other main health care concerns: cost and access. “Quality is the lever that can move both,” he said.


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