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Medicare's Drive for Quality: Full Speed Ahead
by Mary Ferris, M.D., M.S.Ed.
Geriatric Times May/June 2001 Vol. II Issue 3
Are you practicing the quality of care that the Medicare program expects? According to two recent studies, many of us are not measuring up. How Medicare has defined what constitutes quality and how it is being measured are areas of great interest to anyone who cares for older people in America. Furthermore, surveys of our patients show them to be concerned about health care quality too, with more Americans worried about medical errors than about injuries from flying on commercial airplanes (The Kaiser Family Foundation/Agency for Health Care Research and Quality, 2000).Media attention and patient concern will drive us all toward paying more attention to quality measurement and improvement projects. Although no adverse consequences are currently associated with being judged as poor in quality, it has been the intention of the Health Care Financing Administration (HCFA), which operates Medicare, to publicize quality information to allow beneficiaries and their families to better judge their providers. Over 60% of patients surveyed believed that the government should be involved in monitoring and providing information about health care quality.
Quality of health care delivered to Medicare beneficiaries was found to be extremely variable in two massive nationwide analyses reported last fall in JAMA. In the first study, financed by HCFA, up to 4,000 hospital records in every state were analyzed according to 22 different quality indicators (Jencks et al., 2000). To measure mammography usage and diabetes lab testing, the entire set of Medicare provider billing claims for nearly two years were analyzed, involving millions of Medicare bills.
The second study was independently conducted by the RAND Corporation, with funding from the Medicare Payment Advisory Commission (Asch et al., 2000). Researchers evaluated a randomly selected sample of Medicare bills for 345,253 older Americans against 40 quality indicators for 15 common, acute and chronic medical and surgical conditions. Neither of these studies could evaluate beneficiaries enrolled in HMO health plans because individual bills are not submitted for them.
The startling results showed wide differences in quality of health care based on the geographic region of the patient's residence (Figure). For example, the HCFA study found that Montana delivered antibiotics for community-acquired pneumonia within eight hours in 93% of cases, while Florida accomplished this only 76% of the time and Puerto Rico just 38%. Conversely, eligible Medicare recipients in Florida received the recommended angiotensin-converting enzyme inhibitors after acute myocardial infarction in 71% of cases, while Montana only achieved a rate of 59%. The quality indicators measured by HCFA are listed in the Table.
Poor utilization of services was seen in the second study. Although 87% of the Medicare beneficiaries in the RAND sample had visited a physician one or more times in the past year, less than two-thirds received care that an expert physician panel believed met a minimum quality standard. There were also apparent underuse problems when the data were matched with identifiable populations. Both African-Americans and residents of poverty and Health Professional Shortage Areas had significantly worse medical care on a majority of the quality indicators measured. Other ethnic groups such as Latinos could not be evaluated since Medicare records have not accurately recorded ethnicity data until fairly recently.
How were these quality indicators chosen, and why is HCFA so interested in collecting these data? It is all part of a new role for HCFA that has been building over the past five years, following congressional pressure and an embarrassing report from the U.S. General Accounting Office (1996). Medicare, Medicaid and other federal programs cover over 75 million Americans and cost over $200 billion annually, making HCFA the largest purchaser of health care in the United States. Following the model of our major health plans, HCFA decided to change from simply being a passive payer of bills to an agency that demands accountability and value by monitoring outcomes of care. This applies not only to traditional fee-for-service Medicare providers (clinicians, hospitals and nursing homes), but also to the HMO health plans that contract with HCFA. Some have suggested that HCFA is a "sleeping giant" that could play a major role in determining quality standards.
The indicators measured by HCFA were developed in collaboration with the major professional associations, medical specialty societies, academic experts and advocacy organizations, such as the American Medical Association (AMA), the American Diabetes Association, the American Hospital Association and the American Heart Association. They reflect evidence-based standards of care and widely accepted care guidelines in most cases. Even more importantly, HCFA worked with the National Committee for Quality Assurance to align its indicators with the Health Plan Employer Data and Information Set (HEDIS) indicators that are now collected by health plans to satisfy employer purchasers. For health care providers who have been besieged by different agencies and insurance companies collecting myriads of data and copies of medical records, it is some relief to at least have some uniformity in the information being collected.
The RAND study, on the other hand, introduced a different system for selecting which quality indicators to measure. They used an expert panel of medical specialists to establish the risk/benefit balance of evidence-supported common indicators. Then a "modified Delphi method," which RAND has previously validated in other projects, established majority consensus among the panel. Although many of the indicators chosen were the same as HCFA's, RAND used others as well. HCFA measurements mostly focused on acute-care processes, such as administration of aspirin within 24 hours of acute myocardial infarction (AMI), while the RAND study looked at subsequent care, such as the occurrence of a follow-up visit after an AMI within four weeks of hospital discharge. Since RAND limited its study to only Medicare bills, it was unable to measure the detail of care delivered that HCFA obtained by analyzing individual hospital records, but the RAND study was also much less expensive to conduct.
But does the measurement of these indicators really reflect the quality of health care given, or is this one more government intrusion in clinical practice that distracts from patient's real needs? The indicators must be precisely defined and tested, and exclusions must be established to reflect cases that are exceptions to the guidelines. For example, anticoagulation treatment in patients with chronic atrial fibrillation is known to decrease later strokes, but because the evidence for this is not as strong in younger patients, they should be excluded from the measurement, along with older patients who have a preexisting bleeding disorder that would contraindicate anticoagulant medications. Exclusions must therefore be made before records can be analyzed for anticoagulation medications.
Since the measurement of actual outcomes (the occurrence of acute stroke in this example) generally takes many years to accumulate, most of the indicators measure processes, or certain services in health care, that have evidence supporting their critical value in the desired outcome. Mammography usage is measured as a quality indicator for early detection of breast cancer that lowers mortality, but breast cancer diagnosis itself is not an indicator. We are asked to trust the research evidence that shows that these processes (such as anticoagulation to prevent stroke or screening mammography to detect early breast cancer) will prevent disease and result in a higher quality of health care for older Americans.
Even after acknowledging problems in data collection and methodology, these large studies demonstrate that variability in health care is a problem for older Americans, despite the fact that Medicare provides uniform coverage of benefits. Most of the effort by HCFA is focused on measuring the underuse of recommended services, but as the Institute of Medicine's (IOM) National Roundtable of Health Care Quality argued, quality of care problems related to negative outcomes can also arise from overuse and misuse (Chassin and Galvin, 1998).
The quality measurement drive is gradually being merged with the current interest in preventable errors in medicine or patient safety. As part of the large Quality of Health Care in America Project, the IOM issued a recent report, "To Err Is Human: Building a Safer Health System," summarizing evidence that our current health care system frequently falls short in its ability to translate clinical knowledge and technology into practice. In their strong indictment, the authors declared that the health care system as it is currently structured cannot consistently deliver effective care in a safe, timely and efficient manner (Kohn et al., 2000).
Subsequently, the health care industry and provider organizations have focused new attention on problems in delivering care that can be overcome with better systems, such as ensuring that the correct medications are administered to our patients and that the right body part is identified for surgery. In many cases the errors are not attributed to lack of knowledge or incompetent providers, but rather to large organizations with many potential gaps in delivery where errors can occur.
On March 1, the same IOM quality committee issued a new report proposing a bold overhaul of the U.S. health care system. In "Crossing the Quality Chasm: A New Health System for the 21st Century," the IOM again lamented the fragmented delivery system that often wastes resources by duplicating efforts, leaving unaccountable gaps in coverage, and failing to build on the strengths of all health professionals (Committee on Quality of Health Care in America, 2001). The report established a set of performance expectations and 10 new rules to guide patient-clinician relationships. Already, the nation's largest medical organizations representing over 500,000 physicians have declared their support, and, in an unusual joint statement, they called for national reform and reorganization (AMA, 2001).
With the engine building speed, the drive for quality will be with us for some time, and we can only hope that it will lead to positive changes for the way we deliver health care to our older patients.
Dr. Ferris is a geriatric consultant for CMRI, California's non-profit peer review organization funded by the HCFA.
References
AMA (2001), Key physician groups respond to IOM quality report. Press release, March 1. Available at: www.ama-assn.org/ama/pub/article/1616-3969.html. Accessed March 29.
Asch SM, Sloss EM, Hogan C et al. (2000), Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims. JAMA 284(18):2325-2333 [see comment p2374].
Chassin MR, Galvin RW (1998), The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 280(11):1000-1005 [see comments].
Committee on Quality of Health Care in America (2001), Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine. Washington, D.C.: National Academy Press. Available at: www.nap.edu. Accessed March 29.
Jencks SF, Cuerdon T, Burwen DR et al. (2000), Quality of medical care delivered to Medicare beneficiaries. JAMA 284(13):1670-1676.
The Kaiser Family Foundation/Agency for Health Care Research and Quality (2000), National survey on Americans as health care consumers: an update on the role of quality information. Available at: www.kff.org. Accessed April 18, 2001.
Kohn LT, Corrigan JM, Donaldson MS, eds. (2000), To err is human: building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine. Washington, D.C.: National Academy Press. Available at: www.nap.edu. Accessed March 29, 2001.
U.S. General Accounting Office (1996), Medicare: federal efforts to enhance patient quality of care. GAO/HEHS-96-20. Available at: www.gao.gov. Accessed March 29, 2001.
