Managed Care is Not the Problem, Quality Is
Jan 1, 2001
A presidential commission has recommended strategies for defining, measuring, and promoting quality. The private sector is eager to use information about quality to help employees make better choices among clinicians and health plans, a trend known as "value-based purchasing."
Is the quality of U.S. health care adequate? Is it getting better, worse, or staying the same?
Surprisingly, the answer to these questions is, "We don't really know." Drs. Mark Schuster, Elizabeth McGlynn, and Robert Brook, national experts on quality of care, observe that "more information is available on the quality of airlines, restaurants, cars, and VCRs than on the quality of health care." However, their review of nearly 50 studies published over the past decade suggests that quality varies substantially across physicians, hospitals, geographical locations, types of care, and age groups. These studies provide no evidence that managed care has perceptibly improved or worsened quality.
Quality of care can be defined on two dimensions:
In practical terms, poor quality can mean too much care (e.g., unnecessary surgery), too little care (e.g., not providing an indicated diagnostic test), or the wrong care (e.g., an excessively high dose of a medication).
Assessments of quality usually ask whether the right choices are made in diagnosing and treating the patient. One way to answer this question is to determine whether the care given is appropriate—that is, the expected health benefits exceed expected risks. Care that it would be considered unethical not to provide is necessary care.
Criteria for judging appropriateness and necessity can be used to measure both overuse and underuse. These criteria, or quality indicators, are usually based on a combination of scientific evidence found in the research literature and the judgments of panels of experts.
Schuster, McGlynn, and Brook reviewed studies of the quality of care published in the leading professional journals over the past decade. They divided their review into preventive (e.g., cancer screening), acute (e.g., ear infection), and chronic (e.g., diabetes) care because some people may value information about, for example, the quality of preventive care more than information about the quality of acute care. The 48 articles from which they report data cover services delivered to one-half million people for a broad range of conditions and settings.
The authors present these data in a series of tables describing the health care service, the group of patients included in the study, the source of the data used, and the findings about quality. In the absence of a national quality-tracking system, the authors argue, these snapshots are the best way to provide an overview of the quality of care across the nation. The table below provides highlights of their review.
What conclusion emerges from this literature survey?
There are large gaps between the care people should receive and the care they do receive. This is true
Emphasizing that the studies reviewed include different populations, time periods, and methods, the authors offer some simple averages as a rough summary of their findings.
The gap between recommended care and care received is not merely a matter of academic concern. The gap can translate into lives lost. For example, the findings of a representative national study clearly showed that hospitalized patients who received lower-quality care—that is, did not receive services that they needed—are more likely to die.
Many observers have blamed managed care, with its emphasis on cost containment, for much of the poor care found in the U.S. health care system. Empirical studies do not confirm this assertion. Managed care has not substantially improved or worsened quality over that available in the fee-for-service system.
Problems with quality predate managed care. Indeed, the findings from the review of the current literature 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 words managed care received national attention.
A disturbing national picture emerges from these discrete snapshots. The quality of care people receive often depends on which physician or hospital they choose, or in which city or state they receive care. Even the best care often falls short of professional standards.
Just spending more money will not solve the problem. Indeed, a major part of the problem is overuse, which is wasteful and potentially harmful to health. On the one hand, eliminating such care has the potential to save money without harming health. On the other hand, many people receive either too little or technically poor care. Fixing these problems may increase expenditures and would improve health.
Essential to improving quality of care is measuring it and providing that information, routinely and in an interpretable form, to clinicians, health plans, consumers, and policymakers.
We have the tools to measure quality. Over the past decade, RAND has developed more than 1,000 criteria that form a comprehensive set of measures of the quality of care delivered to men, women, and children. We have developed mechanisms to obtain this information from both patient surveys and medical records. We have also developed measures of health status and patient satisfaction that can be used to assess the effects of changes in health care policy.
The United States urgently needs a strategy for routine monitoring and reporting on quality, including a plan to develop the information systems needed to support those activities. Such a strategy could be organized by the federal government, by the private sector, or by a public-private partnership—or it could involve all three.
The quality problem is too pressing to be ignored. As Brook puts it: "Americans tolerate more variation in the performance of their health care system than they would ever put up with in the performance of an airline, a computer company, or even the manufacture of their breakfast cereal. We have to change that. We must make quality and cost equal partners and produce health systems that will truly benefit the patients and communities of the 21st century."
|Recommended Health Care Service||Quality of Care||Reference|
|Routine childhood vaccines||74% of children received all recommended vaccines||CDC, 1997|
|Annual influenza vaccine for all people over 65||52% received annual influenza vaccine||CDC, 1995a|
|Pap smear every 1–3 years for women over 18||67% had Pap smear in prior 3 years||CDC, 1995b|
|Antimicrobial drugs not appropriate for viral upper-respiratory-tract infection||16% of all antimicrobial drug prescriptions in 1992 were written for upper-respiratory-tract infections||McCaig and Hughes, 1995|
|Care for hip fracture||67%–94% of patients with hip fracture received appropriate components of care||Kahn et al., 1990|
|Routine prenatal screening tests||Across 6 HMOs, women received 64%–95% of 7 recommended tests||Murata et al., 1994|
|Dilated-eye examination to screen for diabetic retinopathy||Less than two-thirds of patients at high risk had recommended eye exam in past year||Brechner et al., 1993|
|Beta-blocker therapy can reduce post–heart attack mortality by as much as 24%||45% of heart attack patients received beta blockers before or at time of discharge||Ellerbeck et al., 1995|
|Persons on antidepressants should be given adequate doses||33% of depressed patients discharged from a hospital with antidepressants had doses below recommended level||Wells et al., 1994|
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