The quality crowd is starting to feel like the Rodney Dangerfield of healthcare. Quality can't get no respect.
The public doesn't pay much attention to quality indicators when choosing health plans, physicians or hospitals. The laboriously compiled tables and report cards for consumers are largely ignored. Employers and purchasing groups make a big to-do over working quality calculations into their offerings but don't push employees to consider them.
"The ship of error reduction is under way," said Lucian Leape, M.D., one of its captains. "But the honeymoon may be coming to an end. We may not get this ship out of the harbor."
Leaders of the healthcare quality movement last week appealed to journalists, of all people, for a therapeutic intervention: How can we make quality matter?
The Institute of Medicine's Committee on Quality of Health Care in America invited about 15 healthcare journalists from publications around the country, including MODERN HEALTHCARE, to a roundtable workshop April 8 in Washington. Started in June 1998, the IOM's quality initiative has been trying to provide leadership, strategic direction and analytic tools to improve healthcare quality in the next decade.
In a briefing book, the IOM described the problem: "What does the public think quality of care means? We believe that for many people quality is equivalent to choice of clinician; timely, broad and unhindered access to services; and a personal relationship with someone you trust. To health practitioners and researchers, quality of care denotes primarily the technical process of care."
Or as Richard Sorian, a researcher at Georgetown University, put it: "What consumers want doesn't correspond to what we think consumers need."
Many institutions in the quality vanguard, such as Intermountain Health Care in Salt Lake City; Rochester, Minn.-based Mayo Clinic; and CareGroup in Boston, are stumbling in their efforts to reap rewards from their heavy investments in quality.
Even something as basic as defining healthcare quality is no walk in the park. Is it error reduction? Is it patient satisfaction? Is it process control and system redesign? Should the government use the medical licensing process to enforce quality, or should the marketplace weed out underperforming providers?
A colloquy between Lee Newcomer, M.D., chief medical officer of Minneapolis-based HMO giant UnitedHealth Group, and Leape, the guru of error reduction at the Harvard School of Public Health, illustrated two of those divergent philosophies.
Leape, a retired surgeon, said: "We really need a Federal Aviation Administration for healthcare to set standards and enforce them. We need some kind of regulatory oversight."
Newcomer demurred, arguing for a market mechanism. "We've got to change the fundamentals of how we pay for healthcare," mainly by introducing more-sophisticated incentive structures, he said. "Maybe create a $10 copayment to go to a quality cardiac center and a $300 copayment to go to this mediocre cardiac center," he suggested.
Sometimes Newcomer visits physician groups in UnitedHealth's network and finds patients have a 50% immunization rate. Asked why they don't have a 95% rate, the groups usually tell him they "don't want to invest the time or the money, and nobody's complaining about it. And then they ask me, 'Would you pay me any more if I had a 95% rate?' They know the answer is no."
Charles Buck, a healthcare executive with General Electric Co., said, "If we can get even a part of the market threatening to vote with their feet, it will have an enormous effect on the marketplace."
The trouble is that only a small minority of the public understands statistics and can use the kinds of consumer information that healthcare researchers are publishing, said Robert Blendon, a Harvard pollster who moderated the roundtable. For the rest, choice of healthcare provider is a matter of hearsay, anecdote, personal relationship or convenience.
To get healthcare quality on the larger public's radar scope, it may be necessary to frighten them into paying attention, several participants suggested. Quality emerged as an issue in 1995 when the media covered several dramatic patient-care disasters, such as the accidental death of a Boston Globe writer from a chemotherapy overdose, and the amputation of a wrong leg in a Florida hospital.
But Christine Cassel, M.D., chairwoman of the geriatrics department at Mount Sinai Medical Center in New York, said she doubted whether "this image of two 747s full of people going down every few days (as a result of poor medical quality) is the image we want to put before the public. People are worried enough."
The journalists at the roundtable didn't have any answers for the quality experts, except to advise them that journalists write about news, not public policy. Several reporters bridled at the suggestion of Mary Wakefield, director of the Center for Health Policy and Ethics at George Mason University in Fairfax, Va., that they are "change agents" for the healthcare delivery system.
Laura Meckler, an Associated Press reporter in Washington, explained that editors don't like "thumb sucker" stories or long analytical explanations of complicated issues such as healthcare quality.
Mark Chassin, M.D., chairman of the department of health policy at Mount Sinai, said, "We still don't have a strategy. If we want to start a social movement to improve quality, news stories are not a strategy."