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Quality, Quality Assurance, and the Health
Care System

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health care providers collectively examine information on current practice patterns and determine the reasons for variation and the preferred methods of treatment, the potential payoff in terms of improving overall levels of quality is considerable.

Quality assurance systems typically concentrate on quality assessment and on the identification of the relatively small number of providers whose care is obviously unacceptable. They do comparatively little in attempting to directly improve the overall levels of quality provided by the majority of health professionals. This is more difficult to accomplish, particularly if imposed on health professionals from the outside. If we think of the performance of health care providers in terms of the bell-shaped curve of a normal distribution, the challenge is to devise a quality assurance strategy that not only deals appropriately with the outliers but also assists in moving the entire distribution to a higher level of quality.

Quality is potentially influenced by almost every aspect of the design
and performance of the health care system. While it is important to
have effective systems for monitoring the quality of care after it is pro-
vided, it is equally, if not more, important to try to "build it in" up front.
In particular, having access to needed services is a prerequisite for
receiving services of high quality. For example, if a program

does not cover a range of preventive, acute, and continuing services that are needed by the eligible population, then individuals may not have access to needed services;

does not allow adequate reimbursement for certain services, then providers may decline to provide those services and access to care may be impeded;

has inefficient or burdensome administrative requirements, then providers may choose not to accept patients covered by that program, again curtailing access;

has limited ability to direct patients to high-quality providers or to foster quality among participating providers, then the care patients receive may be of varying levels of quality.

Systemic issues also affect quality. For example, an oversupply of a particular medical specialty or hospital service in a given area may mean that no provider serves enough patients to develop and maintain necessary skills or that unnecessary services will be provided in order to maintain patient volume. Malpractice is another example. The fear of

Quality, Quality Assurance, and the Health
Care System

malpractice suits may cause some providers to give care that is not needed and, in the case of invasive procedures, put the patient at unnecessary risk. High malpractice premiums and judgments may contribute to increasing health care costs, thereby lessening access to care for some people. While a detailed consideration of these issues is beyond the scope of this report, they are nonetheless important and deserve attention. Some of them are being addressed in other studies under way at GAO.

Quality Assessment and Assurance Occur at Many Levels

Throughout the nation, many existing programs of quality assessment
and assurance can provide a foundation for the review of quality under
new initiatives to expand health care coverage. Purchasers of health
care have instituted quality assessment and assurance programs to ful-
fill their fiduciary or public accountability responsibilities to persons
whose care they finance. The Health Care Financing Administration
conducts quality assurance activities for Medicare through its system of
Peer Review Organizations (PROS) for primarily hospital and some ambu-
latory care and through carriers and intermediaries for nonhospital
care. The Health Care Financing Administration's annual release of hos-
pital mortality statistics and information on the quality of care in nurs-
ing homes are additional examples of such activities. State Medicaid
agencies have requirements to monitor the use of services by Medicaid
recipients; this is accomplished in a number of states through contracts
with the PROS. Finally, private insurers also have quality assessment and
assurance systems that resemble those of Medicare and Medicaid but
also vary, depending on the needs of the health care purchaser and
reimbursement methods.

The approaches above to quality assurance are sometimes referred to as "external," "regulatory," or "administrative" quality assurance. Their intent is to make sure that the care for which payment is made is appropriate. There is an emphasis on utilization control, although outcomes and other aspects of quality may also be examined, as exemplified by the PRO's use of generic quality screens. The reviews of care are frequently conducted far from the site of care. While there may be some interaction with, and feedback of information to, the providers whose care is being reviewed, the providers themselves are not deeply involved in the process of review. Quality assessment is a more dominant feature of these activities than quality assurance.

The quality of care may also be monitored and influenced at the community level or within a health service area. In addition to the review of

Quality, Quality Assurance, and the Health
Care System

the quality or appropriateness of individual services, quality-relevant issues to be addressed include whether there is an appropriate supply and distribution of health care providers of various types and specialties, whether the volume of services provided by individual providers is high enough to maintain acceptable skill levels, and whether effective mechanisms exist to refer patients to needed services, coordinate those services, and place patients at appropriate levels of care. Because of the highly individualized and dispersed nature of health care, many communities lack a structure for making such judgments and exerting leverage on the health care system. However, there are some voluntary efforts to develop community-wide programs. For example, a plan called Cleveland Health Quality Choice, involving the physician, hospital, and business communities, is committed to evaluating the quality of hospital care in the Cleveland area and directing patients to hospitals providing high-quality care. In Minnesota, the Twin Cities Voluntary Health Care Information Project is reviewing quality indicators for hospitals and health plans in hopes of assisting health care purchasers and providers in making purchasing decisions.

Finally, many health care institutions, as well as individual providers, have voluntarily implemented their own internal quality assurance programs, reflecting a commitment to what has been termed "continuous quality improvement." The Harvard Community Health Plan, for example, has developed and implemented a program to measure quality of care that generates information to be used by clinicians and managers for identifying the reasons for problems and instituting changes intended to improve the quality of care. The Park Nicollet Medical Center in Minneapolis has developed an internal system for monitoring health care outcomes, concentrating initially on patients with heart disease and arthritis. Individual hospitals have instituted similar approaches. Small physician practices, lacking an organizational structure and patient volume to warrant a structured, statistical reporting system, have nevertheless implemented ongoing quality reviews through such approaches as bringing in outside peer reviewers to review their case records and to give them feedback on strengths and areas for improvement. The key to these initiatives is that they are voluntarily and internally generated. The health professionals involved are committed to determining the levels of quality of the care they currently provide, identifying opportunities for improvement, and seeing that improvement occurs and quality is ensured.

Some health care analysts have viewed these various levels of quality assessment and assurance as being either redundant or in opposition to

Quality, Quality Assurance, and the Health
Care System

one another, if not actually working at cross purposes. This is particularly true when the paperwork and administrative requirements of external reviews are burdensome and are not viewed as adequately addressing and resolving true quality problems. However, there are examples of situations in which the various levels have been complementary and mutually reinforcing. And, in some instances, the presence of external review has provided an impetus for initiating internal reviews.

We believe that the important thing to note is the considerable body of knowledge about, and experience with, organizing and conducting quality assessment and assurance activities. There also appears to be growing interest in improving and expanding these activities among many of the participants, including the medical community, consumers, employers, and purchasers of care. While this interest could be manifested in an increased regulatory burden, it could also be developed into a more balanced system of quality assurance that uses external entities to monitor overall levels of quality of care and identify potential problems. More direct interventions could be limited to instances in which serious quality problems are confirmed or when a provider's internal quality assurance mechanisms appear to have failed. The hope that a better balance between internal and external quality assurance can be achieved has shaped many of the observations and suggestions in the next section.

A Comprehensive, National Quality Assurance Strategy Is Needed

We believe that a comprehensive, national approach to quality assurance is required. By comprehensive and national we mean that, regardless of the source of payment or individual patients' circumstances, similar individuals with similar medical needs should be assured of receiving the same type of appropriate, high-quality care. This implies that similar requirements for quality assessment and assurance should apply across all purchasers, providers, and health care settings. We begin this section by discussing why we believe that a comprehensive national strategy is needed. We then discuss the desirability of blending into a balanced national system an external quality assurance capability together with a community of health care providers who are committed to continuing self-assessment and improvement.

Finally, we describe the essential elements of a comprehensive national strategy and discuss what is needed to move from the current quality assurance environment toward a comprehensive national strategy. The elements that we see as essential are national practice guidelines and standards of care, enhanced data to support quality assurance activities, improved approaches to quality assessment and assurance at the local level, and a national focus for developing, implementing, and monitoring a national system. Although components of each element exist today, it will take time and effort to develop, implement, and refine the type of comprehensive national strategy we envision. But much of the groundwork has already been laid.

Reasons for a
Comprehensive
National Strategy

We believe that a comprehensive national strategy is important for several reasons. The first is equity: the intent and stringency of quality assurance requirements should not depend on whether the care is financed by Medicare, Medicaid, expanded employer mandates, or some other arrangement for coverage expansion. However, some variation or flexibility in the specific review approaches is probably warranted to account for differences in covered populations, types of services, or reimbursement methods. For example, the focus of review for a population consisting primarily of mothers and children might be different than that for predominantly middle-aged employed persons. Similarly, assessment methods for persons enrolled in a prepaid group practice might concentrate on potential quality problems associated with underuse of services, while those for persons whose care is reimbursed on a fee-for-service basis might concentrate on the potential for overuse. Nevertheless, the overall intent and stringency of review requirements should be similar.

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