The Quality of Medical Care in America Don Berwick

Outline We already addressed coverage. Today, we cover cost and quality. Dimensions of quality 1 What we know about quality 2 Aggregate evaluation of quality 3 The policy landscape 4 Key point: quality is a system issue, not a personal issue.

Dimensions of Quality

Institute of Medicine: 6 measures of quality (STEEEP) IOM, 2001

Ways of measuring quality QR24, Fall 2005, Lecture 15 Ways of measuring quality Technical expertise Are error rates sufficiently low? Health outcomes Is health improved? Patient satisfaction Do people like receiving care?

Evaluating Quality Should Be Done Yes No Yes Is Done No QR24, Fall 2005, Lecture 15 Evaluating Quality Should Be Done Yes No Yes Is Done No

The Quality Ideal Should Be Done Yes No Yes ☺ Is Done No ☺ QR24, Fall 2005, Lecture 15 The Quality Ideal Should Be Done Yes No Yes ☺ Is Done No ☺

QR24, Fall 2005, Lecture 15 The Quality Reality Should Be Done Yes No Yes ☺ Overuse [Misuse] Is Done No Underuse ☺

What We Know About Quality

Overuse: Stenting (PCI) Primary PCI (< 12 hours of a heart attack) associated with improved survival PCI > 12 hours for heart attack patients, or for patients with stable coronary disease not associated with reduced risk of death, MI, or other major cardiovascular events 71% of stents for acute conditions  99% appropriate 29% of stents for nonacute conditions  50% appropriate; 38% unsure; 12% inappropriate

Stent rates vary enormously across areas – much more so than heart disease

Mistake 1: Overuse Should Be Done Yes No Yes ☺ Overuse Is Done No QR24, Fall 2005, Lecture 15 Mistake 1: Overuse Should Be Done Yes No Yes ☺ Overuse Is Done No

More on geographic variation Divide areas of the country into quintiles, based on spending McAllen, TX

Consequences of geographic variation Look at risk of death for patients with similar conditions, in areas with high and low spending  No difference

Why does this happen? Money – doctors earn more for doing more Patients – my neighbor had it and is doing well Defensive medicine Can’t do nothing

Underuse: Care for Diabetics

Physiological implications

Appropriate care

Care Management for Diabetics QR24, Fall 2005, Lecture 15 Care Management for Diabetics Source: NCQA data, State of Health Care Quality, US PPO’s.

Share of Diabetics Receiving Recommended Care

QR24, Fall 2005, Lecture 15 Mistake 2: Underuse Should Be Done Yes No Yes ☺ Overuse Is Done No Underuse

We Know We Can Do Better Combination of IT and people QR24, Fall 2005, Lecture 15 We Know We Can Do Better Combination of IT and people Contact physicians, encourage appropriate screening Work with patients on behavioral changes, coming in to MD

Why don’t doctors do this? Money – they are not paid for it Fragmentation – people are in and out of coverage; in and out of different insurance plans Professionalism – It’s not what being a doctor is about

Misuse: Back to heart attacks QR24, Fall 2005, Lecture 15 Misuse: Back to heart attacks CABG Mortality by Annual Volume CABG Volume in California and Canada

QR24, Fall 2005, Lecture 15 Mistake 3: Misuse Should Be Done Yes No Yes ☺ Overuse Misuse Is Done No Underuse

QR24, Fall 2005, Lecture 15 Medical errors About 3 to 4 of every 100 cases in a hospital involve an error, one-third of which are negligent Most common error: giving patient the wrong drug. Example: Betsy Lehman Example: Operating on the wrong patient Example: ER, the TV show http://www.youtube.com/watch?v=4IG8ItaTTzY

QR24, Fall 2005, Lecture 15 Medical errors Institute of Medicine, 1999

Why does this occur? Money Social mission in doing more CABG brings in money Computer systems cost money Social mission in doing more

Aggregate EvaluAtion of Quality

Result 1: Wasted resources 1/3 of spending not associated with improved health Source: Berwick and Hackbarth

QR24, Fall 2005, Lecture 15 Result 2: Poor outcomes Quality of care in American medicine is low (Berwick) Not a statement about HMOs or managed care; it’s a statement about medicine as a whole.

How much are we underperforming? Should the US be up here?

The Policy Landscape Coverage Costs/quality

Proposals address different populations Private - employer Income Mix – exchange; employer; individual Medicare Medicaid 0 18 65 Age

The policy playing field Consumerism Single payer Payment Reform Insurance Medical care Medicare for all Bring everyone into ACA; Reorient provider payments Premium support (aka vouchers) High deductible health insurance Ex: Canada Ex: Kentucky; Massachusetts Ex: Auto insurance Ex: Lasik; Cell phones 1. Watch these videos before next class! 2. Also, go to https://www.mahealthconnector.org/ and preview plans. Which plan would you choose?