INTRODUCTION

In the wake of recent policies to contain medical expenditures has come a ground swell of support for public information on the quality of individual medical providers. The call for better information comes from many quarters-policymakers, consumer advocates, large-scale purchasers of medical care, and medical professionals, all groups with a longstanding interest in the caliber of medical care. For quite some time, payment policies that reward the use of extra services and expensive procedures have posed a threat to the quality of care by creating incentives to provide care that may be inappropriate. But recent changes in payment policies have raised concerns from another direction-that hospitals and physicians facing restricted budgets and low payment rates will skimp on services to the detriment of patients' health and that third-party payers will seek low-cost providers with insufficient regard for their quality of care.

In the present environment, at least three rationales lie behind the call for more public information on the quality of medical providers. The most immediate is that people seeking medical care deserve information so that they can avoid poor providers and seek good providers. This rationale assumes that some medical providers may harm patients or may furnish care much inferior to that of other providers. The second rationale for more public information is that over a longer period of time, information on specific providers could form part of a larger effort to educate the public about the quality of medical care. Indeed, informed consumers play a pivotal role in strategies to inject greater price competition into the medical marketplace. According to competitive theory, the decisions of consumers weighing price and quality levels and selecting health insurance and medical providers guide the cost and quality of care that result. As payment changes have made individual consumers, their agents, and medical providers more sensitive to price, it has grown even more important that purchasers of

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The call for better information on the quality of hospitals and physicians has come from consumer advocates, large-scale purchasers of medical care, medical professionals, and policymakers.

medical care (individual consumers, employers, and third-party payers) know about any differences in the quality of care. Only with information about quality will people making decisions be able to weigh quality along with cost. A general educational effort could impart the knowledge and skills to enable people to appreciate differences in the quality of care offered by medical providers.

A third rationale for better public information on the quality of care is to stimulate the medical community, as a collective and as individuals, to improve their quality. From the choices of informed purchasers, medical providers can gain insight into what matters to people who seek medical care. Some policymakers and medical professionals envisage that the increased knowledge from such feedback and the competition for patients will drive medical providers, both hospitals and physicians, to better their own practices.

The current focus on the quality of care needs to be put into the broader context of U.S. medicine. The U.S. medical delivery system has made enormous advances in the health of the Nation,

some to lengthen life and others to improve its quality. Perhaps the very successes of U.S. medicine have spawned the calls for more quality assessment and public information, for along with these achievements, public expectations of medicine and the public's stake in good-quality care have risen. People now have much more to gain from medicine, and much more to lose from poorquality care. At the same time, several studies have found much room for improvement among different types of providers and disturbing variations in the use of medical procedures and hospital care (79,131,215,696). Furthermore, improvements in health have not been uniform or universal, and some people, notably the underinsured and uninsured, receive less care than others.

Congress has long had an interest in public information on medical care, especially as it relates to the Medicare program. In recent years, changes in payment have heightened that interest, as public and private payers have adopted policies intended to increase price competition in medical care. In October 1983, for example, Medicare changed its system of payment for inpatient operating expenses to a system of payments set in advance and varying according to the patient's diagnosis-related group (DRG) (630). Medicare's present payment system gives hospitals an incentive to be frugal about aspects of care that add to their operating costs without adding to their revenue. Sizable reductions in Medicare beneficiaries' lengths of hospital stay and days in intensive care units suggest that medical providers are in fact trimming resource use (620).

Reducing hospitalized patients' lengths of stay and intensity of resource use may improve the patients' health and the quality of care to the extent that nosocomial (hospital-acquired) infections and

SCOPE OF THE STUDY

This OTA report evaluates the reliability, validity, and feasibility of specific indicators of the quality of medical care that purchasers of careindividuals, employers, and third-party payers— might use. Reflecting the committees' interests and OTA's time constraints, the report deals with indicators of quality only for physicians and acute

iatrogenic (medically caused) problems are avoided, that more extensive technology use carries some risk and adds little or nothing to patients' health, and that a shorter stay or lower level of care is equally or more appropriate. On the other hand, the quality of care may be impaired if tests and procedures that would benefit patients' health are not used, if earlier hospital discharge and care at a lower level harm patients' health, or if delay in more intensive treatment jeopardizes patients' conditions. Certain populations are especially vulnerable to the effects of public and private cost containment: poor people because they are more dependent on public programs for their care; severely ill people because providers may wish to avoid their admission, transfer them, or discharge them early; and physically or mentally impaired people because they have less ability to cope with the system.

In this context, the House Committee on Energy and Commerce and its Subcommittee on Health and the Environment requested the Office of Technology Assessment (OTA) to assess whether information could be developed and distributed to the public to assist their choice of medical providers. The committee asked whether there were valid indicators of the quality of care that consumers could use to select physicians and acute-care hospitals. In addition, the Senate Committee on Finance; the Senate Select Committee on Aging; the Subcommittee on Consumer of the Senate Committee on Commerce, Science, and Transportation; and the House Committee on Science, Space, and Technology endorsed the study. The Senate Committee on Finance asked that OTA specifically address several issues related to data, including their availability, confidentiality, and access. This report responds to the requests of those committees.

care hospitals. Although the quality of health insurance plans lies beyond the scope of this study, the conclusions of the study apply to hospitals and physicians affiliated with such plans, including health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Given the report's focus on physicians and acute-care

hospitals, the report also excludes indicators of quality for medical professionals other than physicians and for providers of long-term care, such as nursing homes and home care agencies. Nevertheless, these topics merit attention as policymakers consider consumer choice and public disclosure of information. For most Americans, which physicians and hospitals are financially accessible hinges on health insurance coverage. Within hospitals and other organizations, the quality of care depends not only on physicians, but also on nurses and other health professionals and on coordination among different health professionals (570). The importance of the quality of long-term care has mushroomed as constraints on hospitals have restricted admissions and spurred earlier discharges.

As a result of limiting the analysis to hospitals and physicians, the report considers how to evaluate the care received by people who seek care and receive services, but does not consider how to evaluate the quality of the entire U.S. health care system. Most issues relating to the accessibility of care to individuals are thus excluded from this report. Numerous factors-psychological, physical, social, and economic-determine whether a person seeks care for a medical condition. Among them is the cost that the person expects to pay, which in turn depends on insurance coverage (or the lack of it) and the provider's charges. Most hospitals and physicians practice independently and do not assume responsibility for ensuring that certain services are available to a clearly defined population. It would not be reasonable to hold these providers responsible for the ease of access by all the people in an area. Once an individual has established a relationship with a provider, however, it seems reasonable to hold the provider responsible for making medical services accessible to those patients.

Also excluded from this report are considerations of cost and efficiency. Medical costs indicate what people forgo in other goods and services to obtain the health outcomes that they desire. In making decisions about medical care, purchasers weigh the likely costs and benefits, as they do for other goods and services. In fact, behind many of the recent changes in payment policies has lain the intention of heightening the cost con

sciousness of consumers and providers about using medical services. Although decisionmaking requires consideration of both cost and quality, separating issues of cost and quality reflects that health effects are distinct and that costs are incurred to obtain the health effects desired.

Technology assessment should undergird assessment of the quality of a provider's practice (103). Using standards to evaluate the quality of care delivered to a patient requires that a quality assessor have criteria by which to judge how a particular condition is managed. The development of such criteria, in turn, should be based on knowledge about the efficacy and safety of new and existing medical technologies. Thus, quality assessment requires information from prior technology assessments about the benefits and risks of technologies under routine and ideal conditions of use. For a given technology, an initial technology assessment is unlikely to be sufficient. Since medical technology changes over time, as old procedures are refined and new ones are developed, evaluating care for a particular condition necessitates continual updates on relevant technologies.

The dearth of such information on medical technologies is well known. OTA and others have previously documented the enormous gaps in knowledge about new and existing technologies and have developed relevant policies (53,103,452, 453,628). Although medical technology assessment deserves continuing attention and improvement, this report takes the deficiencies as given, but does not discuss them thoroughly or present policy options to address them directly.

Although the scope of this report is limited to quality assessment and does not extend to quality assurance, the two are closely related. Quality assessment measures and perhaps monitors the quality of medical care, while quality assurance seeks to safeguard and improve quality (186,384). Historically, much of the interest in assessing quality has come from concern about assuring quality, and many of the present activities related to quality fall under the rubric of quality assurance. Some of these, such as a hospital's procedures to screen the credentials of physicians for the staff, relate to the design of the system, while others, such as review of records by hospital committees