Medical care in the United States presents a paradox. At its best, U.S. medicine is a marvel, featuring state-of-the-art diagnostic and surgical technology augmented by sophisticated pharmaceutical agents. Most citizens report that they are happy with their medical care. Yet, at the same time our health care system merits serious criticism: it is by far the most expensive in the world, consuming almost 12 percent of the nation’s gross national product; its health status, as measured by such standard indices as life expectancy from birth or infant mortality rates, lags that of most developed countries; its organization and distribution of health care resources are unbalanced, with a serious skew toward technology-intensive services, sometimes at the expense of primary care, preventive services (especially for the poor), home care, and long term care; and more than 30 million persons lack any form of health insurance, thereby posing severe problems of access and equity.
By contrast, the elderly enjoy comprehensive coverage and usually excellent access to hospital and acute care facilities under the Medicare program. Coverage for ambulatory care is also good, although benefits for home and long term care are limited. By international standards, the U.S. elderly enjoy excellent health status. As judged by life expectancy from age 65, and especially from age 75, the U.S. ranks among the countries with the best longevity in the world.
Driven largely by concerns about relentlessly rising expenditures for medical care, many health policy analysts now believe that explicit rationing of health services is the appropriate strategy for medical cost containment. The prospect of rationing, however, must be viewed in the context that, for the elderly in the United States, utilization of services such as coronary artery bypass surgery, prosthetic replacements of diseased hips,
and treatments for end-stage renal disease already greatly exceed levels occurring in any other country.
As a result of these conflicting trends and forces, the current health care system in the United States presents a confusing picture:
Despite the comparatively high use of medical services, there are strong pressures to increase access and use of virtually every type of health care, including organ system transplants, treatment for AIDS, and long term care.
At the same time, employers, employees, federal and state government, and the elderly are increasingly vocal in their opposition to paying more for medical care for themselves and others.
Governmental and industrial efforts at medical cost containment have been persistent, incremental, and largely ineffective in their overall effect on the costs of medical care. Previous and current efforts include incentives for health maintenance organizations, hospital prospective payment, utilization review, limitations on benefits and eligibility, imposition of copayments and deductibles, mandated local entities to ensure planning of new facilities and technologies, and limits on medical malpractice awards. These cost containment strategies have had, at best, marginal effects on the ever-increasing costs of medical care, and essentially no impact of the quality of care. It is not unreasonable to expect that the current “hot prospects” for medical cost containment, such as physician payment reform and the promulgation of practice guidelines, will be equally ineffective.
An unintended but increasingly intrusive result of the cumulative efforts at medical cost containment has been the establishment of an administrative bureaucracy to review medical care delivered in all sites—hospital, office, home, and nursing home. Although it is unclear that the procedures that have resulted from this effort have reduced the cost of medical care, it is clear that they have introduced a layer of complexity for patients and providers and have contributed to a mounting sense of frustration among physicians.
The advent of sophisticated data collection and analytic techniques, made possible by computer technology, offers the opportunity to measure and compare the outcomes of medical care for certain conditions across comparable settings. In addition, newer ways of conceptualizing the approach to quality measurement and improvement provide the stimulus to reassess our goals and efforts.
Emerging from this tangle has come an increasing concern about the quality of medical care, particularly focused on the question of whether cost containment efforts (both successful and unsuccessful) will harm quality. To address that question it is necessary to define quality of medical care, to measure it, to assess its current state, and to understand how it can be
improved and how it might be jeopardized. From concerns and questions such as these comes this report. Requested by the Congress, the authorizing legislation called for an ambitious and far-reaching strategic plan for assessing and assuring the quality of medical care for the elderly during the next decade. Emboldened by the scope of this charge, the Institute of Medicine study took a broad and comprehensive view. Its deliberations and fact-finding included commissioned papers, public hearings, panel meetings, site visits, focus groups, and many meetings.
The resulting report indicates that although the current quality of medical care for Medicare enrollees is not bad, it could be improved; that the current system in place to assess and assure quality is in general not very effective and may have serious unintended consequences; and that exciting opportunities—still to be tested in the field—are now emerging to set in place a comprehensive system of quality assurance that can address itself to improving the health of the elderly population.
STEVEN A.SCHROEDER
Chairman, Committee to Design a Strategy for Quality Review and Assurance in Medicare