A Comprehensive, National Quality An Improved System of health of the population over time and identify variation in health outcomes and functional status among population groups or geographical areas. This would be useful in monitoring the performance of the health system as a whole and setting national health priorities. For hospital care, it would be possible to build upon existing claims for- Our reviews of the literature as well as the results of some quality review programs leave little doubt that significant numbers of patients are currently receiving inappropriate or poor-quality care. For example, in past studies, we have cited estimates of rates of inappropriate use of surgical procedures ranging from 14 to 32 percent as well as rates of A Comprehensive, National Quality inappropriate hospital admissions ranging from 7 to 19 percent.5 In addition, our evaluations of current quality assurance programs suggest that those programs are not identifying significant proportions of cases with potential quality problems. For example, SuperPRO regularly reviews a random sample of Medicare cases previously reviewed by PROS and typically questions the appropriateness of hospital admission in almost six times as many cases as the PROS. Similarly, our review of the initial screening of cases in military hospitals for occurrences indicating potentially substandard care found that many such occurrences were missed in the initial screening process.7 Despite the importance of continuous quality improvement strategies in the long run, our past work has shown that improvements in external quality assurance mechanisms are needed in order to achieve the goal of appropriate, high-quality medical care for all Americans. We believe that there are a number of key components for improving the conduct of quality assurance within the framework of a comprehensive, national strategy. First, the quality assurance activities need to be conducted by local review entities that are held accountable for identifying instances of poor quality and improving overall patterns of care within their geographical area. Second, the local review entities should have available a uniform set of methods for reviewing care (including practice guidelines and standards), developing and implementing interventions and reporting information on the results of reviews and interventions. Finally, a national organization is needed to develop the national guidelines and review methods and to coordinate and oversee the activities of the local review entities. By local review entities we mean organizations that are close enough to the local health care community that appropriate recognition of the unique circumstances of the community can be made and that the type of balanced quality assurance system we advocated earlier can be fostered and maintained. The state-level PRO program is one organizational model that approximates this goal. The individual PROS are charged with ensuring that the care provided to Medicare beneficiaries is appropriate and of high quality and, at the same time, with maintaining a positive, cooperative relationship with the provider community. 5U. S. General Accounting Office, Medicare: Improvements Needed in the Identification of Inappropriate Hospital Care, GAO/PEMD-90-7 (Washington, D.C.: December 20, 1989), pp. 3-4. 6U. S. General Accounting Office, Medicare, p. 3. 7U. S. General Accounting Office, DOD Health Care: Occurrence Screen Program Undergoing Changes but Weaknesses Still Exist, GAO/HRD-89-36 (Washington, D.C.: January 5, 1989). A Comprehensive, National Quality Greater uniformity and effectiveness in review methods, intervention approaches, and reporting of results will be necessary in order to ensure that all patients are receiving an equally high level of quality. However, moving toward greater uniformity is not meant to imply that all reviews must be identical. Some flexibility is needed to tailor review methods and interventions to specific situations. For example, generally speaking, reviewing the appropriateness of a hospital length of stay would be reasonable. However, since the Medicare Prospective Payment System reimburses hospitals a set amount regardless of the length of stay, the incentive for hospitals is to release patients earlier rather than later. Therefore, the review of the appropriateness of a hospital discharge under Medicare generally focuses on the possibility that premature discharge has occurred rather than on inappropriate days at the end of the stay. A variety of existing methods of quality assessment could serve as the core of the common review approaches. Reviews could be done prior to care being received (prospective review) that typically focus on the need for particular procedures, the appropriateness of the proposed setting (often the hospital), and the proposed length of stay. The limited information available suggests that these reviews are cost-effective. Reviews could be done while the care is being delivered (concurrent review) and would typically focus on the need for continued care but might also address a lack of expected progress or improvement. This type of review tends to be expensive and is often limited to potentially high-cost cases. Reviews could be done after the care is completed (retrospective reviews) that examine the process and outcomes of care based on information contained in the medical record or on the claims form. Reviews based on the medical records are relatively expensive but can address a wide range of appropriateness and quality concerns, including both overuse and underuse. Reviews could be done of aggregate data from either claims or medical records (profiling; small area variation analysis) that focus on identifying providers who differ in one way or another from their peers in their process or outcome of care. These could be used to target both prospective and retrospective reviews. Reviews could be done of prescription drug use, prospectively or retrospectively, that focus on ensuring appropriate use and limiting adverse A Comprehensive, National Quality reactions and also allow the targeting of educational and other interventions for both patients and providers. Similarly, a number of intervention approaches that have been tried could serve as the basis for developing a uniform set of interventions for use by local review entities. One approach is that of undertaking educational interventions aimed at providing the medical community with information on the appropriate uses and costs of various medical services. The evidence on the effectiveness of this approach in changing provider behavior is mixed. Another is to provide feedback of review results to providers, either on individual cases or on aggregate practice patterns. While generally viewed as more effective than simple educational interventions, its usefulness has been limited by the unavailability of comprehensive data across purchasers and settings. Yet another approach consists of restrictions on providers' use of particular services (such as the total number of laboratory tests) or on their practice (such as hospital or operating room privileges). Restrictions have sometimes been met with resistance and often change behavior only as long as they remain in place. One more approach is to offer incentives (such as increased reimbursement, more patients, reduced administrative requirements) for providers to conform to particular standards of medical practice. These are being increasingly used, particularly in managed care organizations such as preferred provider organizations and health maintenance organizations. Last, monetary sanctions can be imposed or providers can be excluded from the program (as in the Medicare program) if they provide poorquality care and are unwilling or unable to change their practice patterns. Additional development, experimentation, and evaluation of both assessment and intervention techniques will be needed in order to create an effective, comprehensive, national strategy. Finally, even though some flexibility in the implementation of reviews and interventions is necessary, a common set of reporting requirements, and particularly reporting categories, will be needed in order to oversee A Comprehensive, National Quality and evaluate the quality assurance activities at a national level. One of the greatest weaknesses of the current system of quality assurance is that there is no simple way to compare information on quality of care from one program to another or to monitor changes in levels of quality over time. This is another area in which developmental work is needed. A National Organizational The Role of Provider We believe a national organizational focus is required to accomplish the Most of the discussion of quality assurance to this point pertains to the review of care provided to individual patients. However, it is also important to review the credentials, facilities, staff, and administrative procedures of health care providers (so-called “structural" quality assurance) to determine a provider's capability or potential for providing high quality care. While such review cannot ensure that quality care is actually provided, it is important for ensuring that at least the necessary elements for providing quality care exist and that providers without those elements are not allowed to participate. Established accreditation or certification programs exist for hospitals, nursing homes, and many ambulatory care settings. However, one setting in which little review of this type occurs is the individual physician's office. We believe that such review may be particularly important for physicians who do not have hospital admitting privileges and who are not part of a larger medical network through which their care might |