The Quality of Medical Care

For many, the quest to extend access to health care has been an important public goal. For decades, progress was made through employer-based coverage, and more recently, extensions of coverage were made through Medicaid, Medicare, the Veterans Administration, the Affordable Care Act, and the Children’s Health Insurance Program. With access closer to universality, quality and cost will become the central health care focus for consumers.

Quality in this context means medical treatment most suitable for the underlying maladies and symptoms. This can also be measured in terms of effectiveness, safety, efficiency, patient-centered, equitable and timeliness of care. In 1999, we were alarmed by the Institute of Medicine’s estimate that 98,000 patients per year were dying from preventable errors in hospitals. Killing patients is a blatant failure in quality, but it gets worse. Newer data place the death toll closer to 200,000 to 250,000.

Death is not the only consequence of medical errors. Errors or failure to comply with established standards of practice can also leave patients on inappropriate treatment plans – delaying their recovery or making them chronically ill, or pointlessly running up treatments costs. Following standards of practice certainly helps avoid these failures, and if there is doubt, seeking a consult (second opinion) is often in order. The odds of two physicians agreeing on the same wrong treatment plan are smaller than the odds of one physician picking a wrong plan. Disagreements are useful insofar as they highlight an unresolved question on what best to do for the patient. That calls for more thought and perhaps a second consult.

As the total number of patients dependent on government funded health care has increased, so has government’s interest in exploiting the connection between treatment quality and cost. Coarse measures such as deaths from preventable errors led some practitioners to oppose public reporting on quality. In some regards, the opposition is well founded.

It is difficult to obtain systematically collected unbiased data and interpretation of the data can be tricky. For example, a hospital may show a disproportionate share of difficult childbirths, while another hospital shows mostly straightforward cases (who had good prenatal care). The second hospital may appear to deliver better quality treatment, but that could be a result of the first hospital’s unfavorable selection of patients. Interpretation of such “quality” differences can be murky.

The quality performance of physicians and hospital is of interest to consumers. If the data that properly characterizes their treatment quality were available, consumers would put effort into understanding what the quality measures mean. This is true especially for those facing a troubling condition or disease. The Centers for Medicare and Medicaid Services (CMS) is also interested in quality measures insofar as they encourage effective treatments, which in the long run conserve medical spending.

To encourage a focus on quality, CMS operates two payment incentive approaches. First, a Merit Based Incentive Payment System scores physician performance based on cost (10%), quality (50%), clinical practice improvements (15%), and electronic health record use (25%). The quality measures generally mean compliance with standards of practice suited to each patient’s condition or disease. These can be arcane standards or practice such as; Adherence to Statin Therapy for Individuals with Coronary Artery Disease, Adherence to Statins Therapy for Individuals with Diabetes Mellitus, or INR (clotting speed) Monitoring for Individuals on Warfarin.

The second approach available to physicians is participation in Advanced Alternate Payment Models such as Comprehensive Primary Care Plus, or Oncology Care Model Two-Sided Risk Arrangement, or Medicare Shared Savings Programs. Again, these are highly technical distinctions between the practice of different treatment organizations. In 2019, physicians paid by CMS will choose either of the approaches to quality improvement and will face a reimbursement adjustment between -4% and +5% depending on their quality performance. By 2022 that adjustment can grow to plus or minus 9%.

The pressure to demonstrate compliance on quality measures becomes stronger over time. As well, through refinements to standards of practice, the meaning of quality becomes clearer for everyone, even though it may necessarily remain rather technical. The movement toward documented quality of medical care is a big step in the right direction. Perhaps along the way, CMS can take additional serious steps toward controlling cost.