Chronic Condition

Quality Deficiencies Pervade U.S. Health Care System

Large gaps exist between the quality of health care that people in the United States should receive and the quality of care that people do receive. These gaps appear across different types of health care facilities, health conditions, health insurance, geographical locations, and age groups.

Those are the dominant findings of a team of RAND researchers who reviewed 48 studies published over the last decade on quality of care. In the absence of a national quality tracking system, researchers Mark Schuster, Elizabeth McGlynn, and Robert Brook conducted their literature review to summarize the quality of care in the United States.

The researchers divided their review into preventive, acute, and chronic care, because some people value information about preventive check-ups or cancer screenings, for example, more than information about acute care for sore throats or ear infections or about chronic care for diabetes or depression. The 48 studies cover services delivered to half a million people for a broad range of conditions.

On average, only 50 percent of people received the recommended preventive care, 70 percent received the recommended acute care, and 60 percent received the recommended chronic care. The problem is compounded by "contraindicated" care, or care delivered that never should have been delivered. About 30 percent of acute patients and 20 percent of chronic patients received contraindicated care.

The gap between care recommended and care received is a matter of life and death. One national study showed that patients at the worst hospitals, ranked by quality of care, were more likely to die of heart failure, heart attack, and pneumonia than patients at the best hospitals. The quality differences translated into 5-8 extra deaths per 100 patients at the worst hospitals.

Mediocrity Is Nothing New

National interest in quality of care has grown dramatically in response to the dramatic transformation of the health care system in recent years. A presidential commission is seeking to define, measure, and promote quality of care amid fears that quality will be sacrificed to control costs under new managed care regimes.

The RAND literature review, however, shows no overall deterioration or improvement in quality as a result of the shift toward managed care. Some studies find that managed care organizations provide better care than fee-for-service, some find that fee-for-service provides better care, and others find that the care is about the same. Results vary depending on the setting, type of care, and methodology.

Unfortunately, research has generally lumped together managed care organizations without distinguishing between health maintenance organizations, independent practice associations, preferred provider organizations, and point-of-service plans. Distinguishing features have not been considered, either, such as the comprehensiveness of benefits packages or nonprofit versus for-profit status.

In the future, it would be more useful to look at the effects of specific characteristics of managed care organizations, the RAND team suggests. For example, inclusion of immunizations in a benefits package may have a larger effect on immunization rates than whether the care is offered by a managed care organization or a fee-for-service provider.

At any rate, problems with quality of care predate managed care. The current findings are consistent with quality assessments under fee-for-service arrangements analyzed as part of RAND's Health Insurance Experiment as long ago as the 1970s, before the term managed care entered the popular vocabulary.

Thus, a disturbing and enduring national picture emerges from these studies. The quality of health care in the United States varies across hospitals, cities, and states. Whether the care is preventive, acute, or chronic, it frequently does not meet professional standards. The table quantifies how frequently several recommended health care services do meet the standards.

Just spending more money on health care will not solve the problem. On the one hand, a major part of the problem is overuse, which is both wasteful and potentially harmful to health. Eliminating such care might save money while possibly even promoting health. On the other hand, many people receive either too little care or the wrong care, such as misdiagnosis and mistreatment. Fixing these problems may improve health but also increase expenditures.

The Remedy: a National Strategy

Essential to improving quality of care is a coordinated national system to measure quality routinely and to communicate the results in a way that is useful for clinicians, consumers, health plan managers, and policymakers. At present, there is only a patchwork of quality measurement systems, with little uniformity, breadth, or ability to produce rapid results. These systems do not yet assess most health care providers in the country, and changes in health care are occurring faster than these changes can be evaluated.

The United States urgently needs a strategy for routine monitoring and reporting on quality, both to preserve the best of the American health care system and to improve the efficiency of service delivery. This strategy could be organized by the federal government, the private sector, or a public-private partnership.

Over the past decade, RAND has developed (a) more than 1,000 criteria to measure the quality of care delivered to men, women, and children; (b) mechanisms to obtain this information from patient surveys and medical records; and (c) measures of health status and patient satisfaction that can gauge the effects of changes in health care policy.

"The United States is capable of setting up a quality measurement system that can provide the multiple participants in the health care system the information they need to ensure delivery of high-quality care," say the researchers. "A strategy . . . is needed now."