Quality of Care in America: A National Assessment
Which Americans are most at risk for poor-quality health care? Virtually all of us, regardless of race, gender, income, or insurance status. So concluded a team of researchers led by RAND analyst Elizabeth McGlynn, who addressed this question as part of the most comprehensive assessment to date of health care quality in the United States. Earlier groundbreaking analysis by the team documented that Americans receive recommended care only about half the time—55 percent—regardless of where they live. The most recent phase of the work examined the relationship between individual socio-demographic characteristics and quality of care. The study focused on a representative sample of the U.S. population for a broad range of conditions in 12 metropolitan areas. To measure quality, the team developed a set of indicators in 30 clinical areas that represent the leading causes of death and disability in the United States as well as the major reasons that people seek care.
Everyone Is at Risk for Poor-Quality Care
The study found that socio-demographic characteristics, including insurance status, make only a small difference in the likelihood of receiving high-quality care. Although disparities in quality exist across groups for different conditions, these disparities are relatively small compared to the gulf between recommended care and the care that all groups actually receive. A comparison between the socio-demographic profiles of two hypothetical patients illustrates this point. How would quality of care differ for a 50-year-old, white, female college graduate with private health insurance and a household income above $50,000; and a 50-year-old, black male with less than a high school education, no insurance, and a household income under $15,000? A stereotypical view of these patients might suggest that the white female would receive substantially better care. However, based on the study’s results, she would receive recommended care about 57 percent of the time, compared with 51 percent for the black male patient. The difference in care between these patients is statistically significant. However, the difference between the two patients (6 percentage points) is dwarfed by the gap between the care needed and the care received (43 percentage points for the female, 49 percentage points for the male).
How to Improve Health Care Quality
The results suggest that quality-improvement programs that focus solely on disparities among socio-demographic groups may miss larger opportunities to improve care. To be sure, policies and programs to reduce disparities across groups are still important as part of overall quality-improvement efforts. However, attacking the quality problem in U.S. health care will also require a focus on large-scale improvements, such as system-wide investments in health information technology, performance tracking, and incentives for improvement. One promising model for change is the Veterans Affairs (VA) health system. The VA possesses a mature electronic medical-records system and decision-support tools for providers at the point of care, in addition to routine measurement and reporting of quality and financial incentives for good performance. With these mechanisms in place, the VA delivers about two-thirds of recommended care. Putting these mechanisms in place in the broader U.S. system would offer significant potential for improving quality of care. The United States should also invest greater resources in making quality-performance information available at all levels. Patients must demand adequate information on quality to make informed choices. Physicians, hospitals, and nursing homes that are held accountable for performance must also insist that the metrics used are comprehensive, clinically detailed, and representative of the type of care provided.
Some Health Care Report Cards May Overstate Quality of Care
It has become increasingly common for public agencies and private groups to create “report cards” to help consumers choose doctors, hospitals, and insurance plans. Yet the most common method for creating report cards may overstate the quality of care that patients receive. This method typically relies on administrative data, such as claims for payment or provider charges, and often does not include information from medical records. A recent RAND study examined the care provided over a 13-month period to a group of elderly patients (65 and older) who were at risk of declining health. When analysts used administrative data to assess the quality of care received by this group, they found that patients received 83 percent of recommended care. However, when analysts graded the same care using a broader set of standards that included information from medical records, they found that the same group received only 55 percent of recommended care. These results suggest that report cards will assess quality of care more accurately if they incorporate both administrative data and patient information. In addition, the results support current calls for creation of computerized medical records. Such records could make it easier to combine administrative data and clinical information into the routine creation of medical report cards.
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