Of the legislative proposals currently on the table, Clinton's Health Security Act goes the farthest in spelling out the functions and framework of a comprehensive quality management program and provides the starting point on which the foregoing discussion is based. In particular, the plan succeeds in the following respects:

Affirms the policy principle that health care plans are responsible for the improved health of the populations served; that ultimately, improved health status should be the outcome of a health care plan;

Creates a national health care information database that serves as the underpinnings for quality assessment and improvement activities;

"The latest version of the Clinton plan substantially weakens the quality management function by penciling out the state based 'Technical Assistance Foundations' which in the original proposal had been assigned the role of designing and

implementing quality measurement and improvement systems."

Enshrines the principle of meaningful consumer choice by promising consumers a "report card" that compares plans and providers within plans not merely on costs, but also on specific performance measures;

Establishes a state-based complaint and appeals office to permit redress for consumers that believe their benefits have been curtailed by competing health plans;

Reaffirms a national commitment to patient outcome research and national practice guidelines.

The greatest failing of the Health Security Act with regard to quality is the conspicuous absence of an ongoing monitoring and quality improvement function. To that end, Health Quality Foundations are proposed, the chief purpose of which would be to provide ongoing system-wide surveillance of quality indicators, with organized feedback and education to providers and practitioners.

There is obviously some ambivalence on this issue within the Administration itself. The latest version of the Clinton plan substantially weakens the quality management function by penciling out the state based "Technical Assistance Foundations" which in the original proposal had been assigned the role of designing and implementing quality measurement and improvement systems. Instead, this state-based infrastructure was replaced with "Regional Professional Foundations" whose mission it would be to develop programs in "life-time" learning for health professionals.

While academic medical centers might usefully play a role in helping drive medical consensus on practice guidelines and providing targeted education to physicians and other health professionals, it is unreasonable to think that an academically-based regional organization could be expected to implement an administratively efficient process for system-wide quality monitoring. In any event, such a role would present an extreme conflict of interest for an academic medical center which is, itself, a health care provider whose

performance should be monitored. A better model would be for academic health centers to work actively with the proposed independent Health Quality Foundations to assure that their expertise and skills are utilized effectively.

The original plan to create a state-based entity, broadly responsible for quality monitoring and improvement, close to local markets, consumers and practicing health professionals would appear to make a good deal more sense. This report advocates that it be reinstated as health reform makes its way towards law.

There are a number of other points on which this proposed plan for national health quality management differs from the Clinton proposal:

There appears to be a need for only a single National Quality Management Council at the national level. Recognizing that schools of medicine and academic medical centers should be encouraged to take leadership roles in helping frame and research clinical quality research, the addition of the National Quality Consortium would appear to have little functional value;

It would appear sensible to locate the data networks at the state level to take advantage of existing local data collection and analysis apparatus;

"A better model would be for academic health centers to work actively with the proposed independent Health Quality Foundations to assure that their expertise and skills are utilized effectively."

It would also appear to be administratively easier and provide less appearance of a conflict of interest to house the Ombudsman program within state government rather than within Alliances. Existing state Ombudsman programs for long term care could be expanded to accommodate this function.

The United States is on the verge of major health care reform based on the managed competition model. As a necessary complement to health reform legislation, this policy report proposes a comprehensive national program to evaluate and monitor the quality of care provided to all Americans regardless of payer, provider, consumer, or site of care. The program must rely on federal mandates for the reporting of health care information and nationally driven policies on clinical consensus, but should be implemented through a statewide infrastructure of Health Quality Foundations interacting with other appropriate regulatory mechanisms. The goals of the program will be to: empower consumers with health care information that can help guide their decision making at all levels in the system; protect consumers from compromises to quality that a managed competition system invites; and facilitate provider quality improvement initiatives through an active program of quality monitoring accompanied by education and feedback.

1

Institute of Medicine, The Journal of the American Medical Association, October 27, 1993, p. 1911

2

Institute of Medicine, Assessing Health Care Reform, National Academy Press, Washington, DC. 1993, p. 35-36

AMPRA-THE ORGANIZATION

The American Medical Peer Review Association (AMPRA) is a national membership association dedicated to improving the quality of health care delivery in the United States for all consumers through the creative application of quality evaluation programs and services.

AMPRA's current membership includes the federally designated Peer Review Organizations (PROs) under contract with the Medicare program. AMPRA works with its members and other interested parties to promote quality evaluation programs at the local level.

To link AMPRA's practicing review community with the work of health services researchers, AMPRA is affiliated with the American Medical Review Research Center (AMRRC), a non-profit, 501 (c)(3) public benefit, research and education organization dedicated to advancing the art science of quality assurance and quality medical peer review. AMRRC is a national information, evaluation, testing, and analysis resource for practical tools, methodologies, and programs in quality evaluation. AMRRC is presently working under contract with the Agency for Health Care Policy and Research to develop practice guideline-based review criteria and performance measures.

For further discussion or additional copies please contact:

Andrew Webber

Executive Vice President

American Medical Peer Review Association

810 First Street, NE, Suite 410

Washington, DC 20002

(202)371-5610 or Fax (202)371-8954

Mr. CARDIN. It is always nice to welcome a friend to the President. Dr. Kerschner.

STATEMENT OF PAUL KERSCHNER, PH.D., CHAIR, COALITION FOR CONSUMER PROTECTION AND QUALITY IN HEALTH CARE REFORM

Mr. KERSCHNER. Thank you, Mr. Cardin. Until 1 month ago, I was one of your very satisfied constituents.

Mr. CARDIN. Did you move or are you just not satisfied now? Mr. KERSCHNER. I got tired of 15 years of commuting and moved into the District to flee the crime in Maryland.

I am the executive director of the Gerontological Society of America and chair of the Coalition for Consumer Protection and Quality in Health Care Reform. The Coalition applauds the President's allout effort to reform the Nation's health care system. Our job now is to recommend specific improvements where necessary.

Mr. Chairman, the Coalition's members know what it is like for health care consumers under the current system. They are vulnerable to losing benefits or being denied coverage. The managed care model relies on competition between health care plans and providers to drive down the cost of care and drive up the quality of care. But there are obvious incentives for plans to contain costs while providing less service, so we believe a systematic approach to protecting consumers must be implemented. Allow me to summarize our recommendations.

Under quality improvement and public accountability, the Health Security Act provides an excellent foundation for independent monitoring of quality. However, the Coalition strongly believes there is a missing component. The bill does not satisfy our basic principle that there must be an external quality review entity independent of the payer-based alliance and provider-based plan, systems to monitor and improve quality in each State.

The Coalition also believes that what we call "quality improvement foundations" should be created in each State by the National Quality Management Council through competitive grants. The QIFS would be governed by a consumer majority board which would also include experts in a variety of health and quality research fields. Each QIF would perform quality monitoring and improve functions such as development of and support for quality improvement activities, practice guidelines, adherence monitoring and profiles of the database for low rates of utilization. This would ensure that quality improvement activities, which are currently very successful in some hospitals and with some health care professionals, will be used consistently across the Nation.

The QIF also will ensure that information regarding consistently poor care and poor plans will be forwarded to the appropriate entities. Under consumer representation, public accountability depends greatly on consumer representation on advisory boards, including the advisory boards for regional and corporate alliances, the National Quality Management Council and the State-located quality improvement foundations. In fact, Coalition members would argue that consumers must have a majority on these advisory boards since they are both the recipients of care and the ultimate source of financing.