Report finds health quality “flat-lining;” reforms could restore momentum

"The quality of U.S. health care was virtually stagnant in 2008, a disturbing slowdown after a decade of improvements," the National Committee for Quality Assurance reported in its annual study of health quality. NCQA is a non-profit organization that collects data on health insurance plans and provides a "seal of approval" for those that meet standards.

On the other hand, provisions in health reform legislation could go a long way toward pushing quality improvement, Margaret O'Kane, NCQA's president, wrote in a post for The Health Care Blog.

O'Kane said that many key reforms - requiring health insurers to report on quality; finding ways to pay for quality of medical services, not just quantity; expanding programs for patient-centered care - are already in some of the health bills in Congress.  What's needed, she said, is to make sure those provisions make it into the final bill.

H.R. 3962, the House reform bill endorsed by CWA, includes important provisions to improve quality, according to an analysis by Timothy Jost for the Web site of Health Affairs, a health policy journal. "Accountable care organizations, bundled payments for hospitals and physicians, medical homes, incentives to reduce hospital readmissions, increasing payments for primary care, quality and efficiency incentives for Medicare Advantage plans, comparative effectiveness research,  promotion of shared decision-making, gainsharing, reporting on infections acquired in hospitals and ambulatory surgical centers, and more--it is all in there," Jost wrote.

NCQA measures quality by collecting data on care such as whether children receive recommended immunizations and whether patients received recommended medications after a heart attack to prevent another attack. The report found some large gaps between standards of care and actual performance.  For example, only 45.3% of people are receiving colon cancer screening at the appropriate age, and only 34.1% of children getting medication for attention deficit hyperactivity disorder (ADHD) are seeing a doctor for needed follow-up care.

The NCQA report also found that "quality of care for Americans continues to vary sharply depending on where people live," with health plans in New England outpacing counterparts in the South Central region by 15 to 20 percentage points on some quality measures.

– 11/10/09

The best health care in the world?

Among the arguments used by supporters of the status quo in health care is this one: The United States has the best health care system in the world, so we don't want to mess it up in an attempt at reform.

Is that true? A new review of quality research by Elizabeth Docteur and Robert A. Berenson, scholars at the Urban Institute, finds U.S. quality ratings are "a mixed bag, with the United States doing relatively well in some areas - such as cancer care - and less well in others - such as mortality from conditions amenable to prevention and treatment."

Moreover, the authors say, "In the light of the fact that the United States spends twice as much per person on health care as its peers, those who question the value for money obtained in U.S. health expenditures on are firm footing."

Some highlights and lowlights from studies of U.S. performance:

• American women have high rates of mammograms and Pap smears, compared to other developed countries, but the U.S. has below-average rates of childhood immunization.
• The U.S. has high cancer survival rates, but low rates in patient safety. A survey of patients found 34 percent reported experiencing medical errors - the highest rate of any country surveyed and double the rate of the Netherlands, which had the best results.
• Among 30 members of the Organisation for Economic Co-operation and Development (OECD), a group of industrialized democracies that collects comparative health data, "The United States is one of only three countries ... together with Mexico and Turkey, which has a sizable share of its population lacking (health insurance) coverage. Many more Americans say they skip medicines or medical treatments because of cost."

Both the House health reform bill - H.R. 3200, endorsed by CWA - and the Senate Health, Education, Labor and Pension (HELP) Committee bill contain a number of provisions to improve quality. For example, H.R. 3200 would adjust create pilot programs for "accountable care organizations" (doctor-hospital partnerships which would provide better coordinated care) and for "medical homes," a patient-centered primary care system. It would also base payments to hospitals on the rate of avoidable readmissions and create a quality incentive system for Medicare HMOs. It would waive Medicare deductibles and co-payments for some preventive and screening tests. It would offer grants to devise, collect and analyze better data on quality.

– 09/02/09

Report finds little progress in patient safety

Ten years ago, the Institute of Medicine touched off a furor in Washington and in hospitals throughout the country with a report called "To Err is Human."  The institute estimated that as many as 98,000 people a year die in the United States because of errors and other preventable medical harm.

But, despite all the attention given to the report in 1999, "Ten years later, we don't know if we've made any real progress, and efforts to reduce the harm caused by our medical system are few and fragmented," according to a recent report from Consumers Union called "To Delay is Deadly."

While evidence is sketchy - that's an important part of the problem - Consumers Union believes that preventable harm still accounts for 100,000 deaths a year.  That means that since the initial Institute of Medicine report, a million Americans have died needlessly.

That's why CWA wants to see improvement in quality as one of the goals for health care reform this year.

Among the recommendations from Consumers Union are better labeling and packaging to prevent medication mix-ups and overdoses; better training and testing on safety for doctors, nurses and other health professionals; and mandatory public reporting of errors and preventable infections picked up in hospitals.

While some states collect such data, the report says, most don't report it to the public. The report says, "Consider if Consumer Reports tested 50 cars and found some performed well and others unsafe, but refused to reveal which cars are which."

– 06/16/09

The need for data and for data systems

All sides in the health care debate support more and better use of electronic medical records.  President Obama's economic stimulus plan includes $19 billion to help doctors and hospitals adopt records systems.  Electronic records are seen as a way to reduce errors and duplication, meaning they'll improve the quality of care and save money in the long run. That fits perfectly with one of CWA's five priorities for health reform legislation this year - to control costs without compromising quality.

A new study in the New England Journal of Medicine shows that the country has a long way to go in building a medical records system, and that federal dollars are likely to help.  The study, by Dr. Ashish K. Jha of the Harvard School of Public Health and eight co-authors, found that fewer than 2 percent of American hospitals have comprehensive electronic medical records systems, although many hospitals have systems that perform limited functions or serve only certain departments.

And the greatest barrier to installing systems - cited by about three-quarters of the hospitals that don't have them - is inadequate capital.  Policy-makers should also look to make sure that the systems are "interoperable" - meaning that the computers at one hospital can talk to the computers at another, or at physician offices - and should find ways to help train technical support staff, the article concluded.

Similarly, the American Academy of Nursing recently called for "thoughtful development" of health technology, giving nurses and doctors more time with their patients "which will result in increased safety, improved clinical outcomes and decreased costs."

Also, a new group called Stand for Quality has called for more collection of health data and for making results public to spur quality improvement.  The group includes representatives of the AFL-CIO as well as such diverse groups as the American Medical Association, the U.S. Chamber of Commerce and America's Health Insurance Plans, the trade association for health insurance companies.

"Dramatic changes are needed to fix our health care system," Stand for Quality said in its initial report. "Information that is grounded in good evidence will support quality improvement, payment reform, and enable better clinical and consumer decision-making."

– 04/02/09

The developed world’s worst health care bargain

The United States spends way more than other developed countries on health care, but gets results that are, in many cases, worse, according to a new study in the current issue of the respected policy journal Health Affairs. The study is based on data collected from its members by the Organization for Economic Cooperation and Development (OECD), which includes 30 developed countries. (Note: The link leads to a summary; the full article is available only to subscribers.)

Reviewing a number of studies comparing health outcomes,  "despite the higher spending, the United State scored average or slightly worse than average on many quality-of care indicators," the authors wrote, "Perhaps even more troubling is that improvements in health status are occurring at a lower rate than in most OECD countries."

The authors are Gerard Anderson and Bianca Frogner of the public health school at Johns Hopkins.  With various co-authors, Dr. Anderson has done such studies for a decade.  That series of reports concluded the United State isn’t getting more care (as measured by such things as number of doctor visits and hospital days) or more resources (as measured by such things as hospital beds per capita or supply of advance MRI and CT scanners).

Rather, we simply pay more for what we get, a conclusion Dr. Anderson summarized as, "It’s the prices, stupid."

This study looked at life expectancy and health spending, both adjusted for per-capita income. The U.S. had by far the highest spending, and in (adjusted) life expectancy it beat only. Hungary among the 30 OECD countries. Besides the U.S., only two other countries - Belgium and Turkey - had both higher-than-expected spending and lower-than-expected life expectancy.

"Health reform efforts should focus on improving the value per dollar spent on health care," the authors concluded, "in addition to other reform goals of extending coverage to all and reducing unnecessary health care spending, so that American get the health care system they are already paying for."

– 11/14/08

Can the U.S. Health System beat Poland and Slovakia?

We're often told that the United States has "the best health system in the world," but comparisons of health statistics with other countries paint a different picture.

For example, the U.S. ranks 29th in the world in infant mortality - tied with Poland and Slovakia - according to a recent report from the National Center for Health Statistics (NCHS). The U.S. rate has been remaining steady while other countries have been progressing, causing the U.S. to drop in rankings from 12th in 1960.

Similarly, a recent column by Dr. Stephen C. Schoenbaum, executive vice president of the Commonwealth Fund, notes that the U.S. ranked 19th out of 19 developed countries in rates of preventable death and that "adults in the U.S. received only half of the recommended screening and preventive care for their age group."

Those results, Dr. Schoenbaum wrote, "underscore the need to implement health reform in the U.S. so that all Americans can have excellent access to excellent care."

The Fund, a foundation that studies health issues, has called for five key strategies for health reform that are similar to CWA’s principles:

1. Extend affordable health insurance to all.
2. Align financial incentives to enhance value and achieve savings.
3. Organize the health care system around the patient to ensure that care is accessible and coordinated.
4. Meet and raise benchmarks for high-quality, accessible care
5. Ensure accountable national leadership and public/private collaboration.

– 10/27/08