A train that hasn’t left the station

One of the most perplexing questions in healthcare is whether quality of care is a national movement, exists only in silos of excellence or merely amounts to good public relations. Despite a multitude of quality organizations, demonstration projects and calls to arms, the hard evidence simply doesn’t back up the claim that things have changed in any systematic way.

This is not to say they won’t, and it is not to dismiss the health systems that have adopted cultures that strive toward cost-effective, safe and high-quality care—even when the payment system fails to adequately reward them for it. Nor is it to minimize the good work of organizations such as the Leapfrog Group and the Institute for Healthcare Improvement. They are the engines pointing the way down the right track; it’s just that not nearly enough cars are in line behind them.

As our cover story this week shows, two new reports on healthcare quality, access and cost at the state level offer yet another depressing view of the numbers. One of them, by the Agency for Healthcare Research and Quality, attempts to be a little bit upbeat, but can’t quite pull it off. It examined 129 different measures of quality across the panoply of care and found that while some states do some things better than others, no state is good at everything.

“The statistics ... underscore the reality that some shortcomings in healthcare quality are widespread,” the State Snapshots report says, in a bit of an understatement. To take just two tiny examples: Only 59% of adult surgery patients insured by Medicare receive antibiotics at appropriate times, and just 54% of Medicare managed-care patients said their providers always paid enough attention to them, an interesting statistic given how that particular bill of goods is being sold in Washington.

Meanwhile, the Commonwealth Fund looked at 32 indicators grouped into five dimensions of state healthcare performance—access; quality; avoided hospital use and costs; equity; and healthy lives. Again, the variability is the key, with some states far outdistancing others on key rankings. To skip to the bottom line: Death rates before age 75 from conditions that might have been prevented with timely and appropriate healthcare are 50% lower in states with the lowest rates than those with the highest rates. As the fund concluded, if every state does as well as the top states, 90,000 lives could be saved annually.

Just as the Dartmouth Atlas Project has concluded, researchers for the Commonwealth Fund project found no statistical relationship between high spending and high quality of care. Some states achieve high quality at relatively low costs, and the states with the highest levels of spending tended to have higher rates of preventable hospital use. Again, the variability is stunning. For example, the rate of children admitted to the hospital for asthma ranges from 55 per 100,000 in Vermont to 300 per 100,000 in South Carolina.

Another report last week, by the Pennsylvania Health Care Cost Containment Council, came to the same conclusion. The study found that payments for heart-bypass surgery varied wildly and bore little relation to the quality of care provided.

Does all of this sound like a health system on its way to better things? It is hard to make that case, as there is scant longitudinal research in this area. Nor are we really sure what even works, as the results of a recent comparative study of the CMS-Premier hospital pay-for-performance initiative and a national quality improvement program sponsored by Duke University revealed (June 11, p. 9). The study found that though both projects have had some success in prodding hospitals to change practices, there is scant evidence that pay-for-performance is enough of an incentive for change.

Instead of paying for incremental improvement, we need to change the payment system to focus on wellness and managing illnesses. Internally, providers need to adopt best practices that are out there for anyone caring enough to find them.

What do you think?

Write us with your comments. Via e-mail, it’s [email protected]; by fax, 312-280-3183.