Download Key Issues to Consider When Evaluating Healthcare Reform Models

Key Issues to Consider
When Evaluating
Healthcare Reform Models
While the quality movement in healthcare has been evolving
rapidly, it is important to keep in mind that quality improvement has long been a part of hospitals’ day-to-day operations. It
is a cornerstone of every hospital’s mission, and they stake their
reputations on their ability to provide quality care.
Hospitals and all other stakeholders operate within a healthcare system that balances the need for high quality care against
access and cost considerations. And although quality improvement initiatives are sometimes considered an extra expense, oftentimes these initiatives actually generate savings by avoiding
additional costs down the road. In fact, this is a strong component of the rationale behind pay for performance.
The increased public attention to quality assessment and improvement is not expected to abate any time soon. As healthcare
reform proposals are debated and politicians explore which
models might be replicated on a national scale, any plan should
be scrutinized based on its ability to achieve the ideal balance of
cost, access and quality. Using this cost, access, quality framework, The Center for Health Affairs has developed a series of
Policy Snapshots that explores each of these three key facets
in detail. In the coming weeks, we will be releasing an Issue
Brief that ties these concepts together to explore which existing
models most successfully address all three dimensions while
minimizing potential unintended consequences.
The Distinction Between Quality of Care &
Health Status
Critical reviews of the U.S. healthcare system sometimes
make the mistake of pointing to the population’s poor health
status as an indicator that there must be a problem with the
quality of care. However, in order to most effectively develop
strategies for improving the U.S. healthcare system, it’s important to distinguish between the quality of care provided by our
healthcare practitioners and the overall effectiveness of system,
which encompasses health status, public health initiatives, research, preventive care, our financing structure and a whole
host of components in addition to the quality of hospital and
physician services.
Data from the Organisation for Economic Co-operation and
sidered in any healthcare system, and they exist in
ss
Access, Cost & Quality: in Perfect Harmony
stool; they are the three elements that must be con-
ce
Accrediting bodies, healthcare providers, payers and business
groups each have spearheaded a vast array of quality measurement initiatives. While they all look a bit different, they share
some basic characteristics: an emphasis on the use of treatment
guidelines for particular illnesses or conditions, the measurement of treatment outcomes, and the reporting of data. Most
recently, payers have begun tying reimbursement to progress on
quality measures, and this trend is expected to continue.
Cost, access and quality are like the three legs of a
Ac
Q
uality is one of the buzzwords in
healthcare today. With healthcare spending on the rise, everyone from consumers to payers to employers wants more information about the return they are getting on their healthcare investment.
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an
a balance. An ideal system could be defined as one
with completely unfettered access, where people
could have on-demand care for their every
Quality
health need great and small; one with perfect quality, with
the best, most-advanced procedures and technologies and
flawless quality control systems; and one that is able to do
all of this at bargain prices. Clearly, compromise is unavoidable, and any existing health system or proposal for reform
must weigh these three elements and make choices regarding cost, access and quality to create an approach that is
best suited to those being served.
Development’s 2007 Health at a Glance help to demonstrate
the difference between health status and quality of care. For
example, while the U.S. is a world leader when it comes to
the percentage of the population that would be categorized as
obese, an indicator of health status, it is also a leader in breast
cancer survival, an indicator of quality of care. The distinction
is important because to be effective, a healthcare system has
to be good at not just treating illness, but preventing it as well,
and this is where the other resources described above, such as
research and public health, are especially important.
What are the Crucial Components of Quality?
Ensuring quality is a complex endeavor. Below are some of
the key issues related to quality that should be considered when
developing or evaluating healthcare reform models.
Recommended Treatment Guidelines
A large part of the quality movement has been focused on ensuring that all healthcare providers are aware of and consistently
follow recommended treatment guidelines that are based on the
best medical knowledge available. For example, research has
shown that the use of drugs called beta-blockers reduces heart
attack mortality in the first week by 13 percent and long-term
mortality by 23 percent1. Given the clear clinical science supporting the use of beta-blockers for heart attack patients, many
payers and accrediting bodies now measure their usage.
Providers support the use of recommended treatment guidelines that are based on clear clinical science and they have
played a key role in collaborating with various organizations
to improve the quality of care provided to patients. At the national level, through the Hospital Quality Alliance hospitals
have partnered with consumer representatives, physician and
nurse organizations, employers and payers, oversight organizations and government agencies to make meaningful, relevant,
and easily understood information about hospital performance
accessible to the public and to inform and encourage efforts to
improve quality.
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Yet as the quality movement has gained traction, providers
increasingly are being inundated with requests for data from
insurers, employer groups, accrediting bodies and government
agencies. As healthcare reform models continue to take shape,
streamlining the number of places and ways in which providers
must submit quality data will reduce confusion for both providers and consumers. Furthermore, attention should be paid
to ensuring that the information consumers receive and that is
sometimes used to determine provider reimbursement is based
on solid data and good measures.
Health Information Technology
The rise of information technology holds great promise for
improving the quality of healthcare. Already the healthcare
field, and ultimately patients, have benefited from the implementation of countless medical technologies, from using bar
coding to provide increased medication safety to utilizing magnetic resonance imaging (MRI) to help doctors make more definitive diagnoses.
Electronic medical records (EMRs), which facilitate access
to comprehensive medical information by a patient’s care providers,
One study put the
have been touted as a way to not only
cumulative cost for 90
improve patient safety but also make
processes faster and more efficient,
percent of hospitals
leading to cost savings. Encouraging
to adopt an electronic
the adoption of EMRs is a positive
step toward improving quality of care,
health record system
yet there are multiple issues that must
at $98 billion if 20
be considered. Patient confidentiality
percent of hospitals
concerns must be addressed and the
up-front cost of these technologies
now have such a
cannot be overlooked. The standard3
system.
ization of technology is another significant challenge to overcome.2
Eliminating Disparities in Care
Central to ensuring that a healthcare system is functioning
well is ensuring that it is functioning well for people of all races
and ethnicities. Yet research has shown that despite efforts by
providers to extend equal care to patients regardless of race or
ethnicity, disparities in care exist.
Many experts believe that a complex host of factors influence the existence of disparities. These can range from systemic
problems, such as financing, geographic location and access to
care, to factors arising from the provider-patient interaction. To
reduce disparities, the healthcare community is working hard
on increasing their collective level of cultural competency.
Progress has been made in developing language access services
that effectively target hospital resources at patients with limited
English proficiency and lead to improved communication between clinician and patient. Staff training programs are increasingly incorporating cultural competency components to ensure
effective communication with all patients who seek care at our
hospitals.
The U.S. is expected to become more, not less, diverse in the
future. As policymakers work on developing healthcare reform
models, supporting providers’ efforts to reduce disparities while
continuing to track healthcare outcomes for different subsets of
the population will remain important.
Eliminating Workforce Shortages
A well-trained and adequate supply of healthcare professionals is also essential to the provision of high-quality healthcare.
In recent years, the growing nursing workforce shortage has
garnered attention. The national shortage of
registered nurses (RNs) is expected to hit
roughly 1 million by 2020, while Ohio is
projecting a 12 percent shortage of RNs
by 2010. Locally, Northeast Ohio is anticipating that an additional 3,887 nurses
will be needed by 2010.4
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Workforce shortages aren’t just affecting
the nursing profession. Shortages of primary
care physicians also exist, as do shortages of certain allied
health professionals, which are healthcare practitioners with
formal education and clinical training who are credentialed
through certification, registration or licensure.
As the population ages, healthcare workforce needs are only
expected to grow. While workforce shortages can impact quality of care, they can also hamper access to care. With quality of
care so closely linked to the workforce, any long-term strategy
for the healthcare system should also address issues of workforce supply.
Changing Course
While the economy has moved front and center in the minds
of Americans, healthcare still remains a key issue for voters
across the country. Eight in 10 Americans believe the U.S.
healthcare system needs to be fundamentally changed or completely rebuilt according to a recent poll, and 90 percent of respondents said they thought it was important for presidential
candidates to have reform proposals that would improve the
quality of care.5
Barring serious healthcare reform efforts, problems associated with the current healthcare system are likely to worsen. Yet
the current trajectory can be altered by implementing the right
healthcare reform policies. As the dust clears from this most
recent election, we hope that the national discussion crystallizes around how to most effectively achieve real change within
the healthcare system that will bring harmony to the goals of
increasing access to healthcare, upholding the highest quality
of care, and making the most out of opportunities to create efficiency within the system and save costs. In the end, individuals ought to be able to receive the highest quality of care, when
they need it.
Wrapping up our series on Cost, Quality & Access and their
role in health reform will be an Issue Brief that will be published in the coming weeks. The brief will explore health reform models based on systems in place in a few of the U.S.
states as well as some other countries. Previous installments
in this series, as well as all of our Policy Snapshots and Issue
Briefs, can be found online at www.chanet.org.
Endnotes
1. Hennekens, C., et al. “Adjunctive Drug Therapy of Acute Myocardial Infarction – Evidence from Clinical Trials.” New England Journal of Medicine, 1996;
335(22), 1660-1667.
2. American Hospital Association. “Improving Quality and Patient Safety.”
http://www.aha.org/aha/content/2008/pdf/08-issue-quality.pdf
3. Hillestad, R., et al. “Can Electronic Medical Record Systems Transform
Health Care? Potential Health Benefits, Savings, and Costs.” Health Affairs.
September/October 2005. Vol. 24, No. 5, pp. 1103-1117.
4 Northeast Ohio Nursing Initiative, The Center for Health Affairs. “Local,
State and Federal Solutions to the Nursing Shortage Problem.” June 2006. http://
chanet.org/NR/rdonlyres/DA757BF5-AA7E-4B7A-8948-033282748F29/192/
policy_solutions.pdf
5. How, S. K. H., et al. “Public Views on U.S. Health System Organization: A Call for New Directions.” The Commonwealth Fund, August 2008.
http://www.commonwealthfund.org/usr_doc/How_Public_Views_8-4-08.
pdf?section=4039
The Center for Health Affairs is a hospital trade association representing 35 hospitals in Northeast Ohio and serving those
organizations and others through a variety of advocacy and business management services.