A 1999 Institute of Medicine (IOM) report, "Ensuring Quality Cancer Care," suggested that many cancer patients in the United States are not receiving the care known to be effective for their disease. The IOM committee recommended a number of remedial steps including the development of a national quality care monitoring system. CC&E spoke with Eric C. Schneider, MD, assistant professor of health policy and management, Harvard School of Public Health, and assistant professor of medicine, Harvard Medical School, about, among other things, the ongoing initiatives to link quality care performance measures to the delivery and reimbursement of oncology services.
ABSTRACT: A 1999 Institute of Medicine (IOM) report, "Ensuring Quality Cancer Care," suggested that many cancer patients in the United States are not receiving the care known to be effective for their disease. The IOM committee recommended a number of remedial steps including the development of a national quality care monitoring system. CC&E spoke with Eric C. Schneider, MD, assistant professor of health policy and management, Harvard School of Public Health, and assistant professor of medicine, Harvard Medical School, about, among other things, the ongoing initiatives to link quality care performance measures to the delivery and reimbursement of oncology services.
CC&E: The 1999 Institute of Medicine (IOM) report "Ensuring Quality Cancer Care" recommended the development of a national quality monitoring system. Do you think this recommendation is feasible?
DR. SCHNEIDER: It depends on how we define a national quality monitoring system. To obtain a highly reliable picture of the quality of cancer care may be an expensive undertaking. It requires creative reorganization of the health system in order to collect data at multiple points and feed the data into central receiving areas.
In 2004, my colleagues and I published an article (J Clin Oncol 22:2985-2992, 2004) addressing the key components needed to move forward on a national quality monitoring system. We selected four areas where there was a need for more work.
The first need is the ability to use our registries effectively to obtain population-based samples of patients with cancer so that their care could be comparatively assessed.
The second need is a system sensitive to existing privacy and confidentiality regulations that would protect the privacy of patients while enabling thorough assessment of their cancer care quality.
The third need is deciding how to select a fairly large number of quality measures to assess cancer care. In a sense, we just scratched the surface of this issue. There is a lot of work to do in developing and defining quality measures.
The fourth need has to do with designing a data collection strategy. We collected our data from patient reports, medical record review, and electronic claims and registry data when those were available. It was a cumbersome and labor-intensive method. That said, under the right circumstances and by tailoring the method, I think developing a monitoring system is highly feasible.
CC&E: Would electronic health information technology help the overall effort to create a national quality monitoring system?
DR. SCHNEIDER: As you know, the Centers for Medicare & Medicaid Services (CMS) is moving very aggressively toward pay-for-performance strategies that will require a large-scale data collection effort. Without strong data, the monitoring systems will collapse because of a lack of credibility. While electronic health information technology could help streamline the data collection effort, it cannot automate or pull out the critical data elements needed to establish accurate criteria.
CC&E: Is the pay-for-performance initiative a constructive methodology for increasing quality care?
DR. SCHNEIDER: It could be, but there are a host of unanswered questions: How do we reach a consensus on quality measures? How do we minimize the data collection burden on busy practicing physicians? How should the payments be set and what is the type of care related to performance that the system wants to reward? Are we talking about rewarding improvement or rewarding achieved levels of performance?
The United Kingdom has a pay-for-performance system in the primary care setting, and their results suggest that UK providers seem to be responding to the financial incentives by reporting data and improving performance. However, we have a much larger population and a very different national health care model.
One final question remains: Will the effort needed to develop a monitoring system produce enough improvement in quality of care to justify its expense?
CC&E: Since the IOM report on medical errors, "To Err Is Human," have we made any progress in reducing medical errors?
DR. SCHNEIDER: The Institute of Medicine called for credible public accountability of our health care system, and "To Err is Human" certainly created that stimulus around patient safety. However, I know that some of the key participants in the IOM report were surprised at just how difficult it has been to improve patient safety on such a large scale. We can point to a few examples in specific settingsintensive-care units, hospital care, and medication prescribingwhere we have made progress, but given the vast set of continuing problems, it's difficult to feel enthusiastic about those small improvements.
CC&E: One of the primary growth
areas in our burgeoning health care budget is high-priced imaging and testing technologies. Should we try to curb unnecessary and redundant use of these expensive medical resources?
DR. SCHNEIDER: There is no question that advances in technology are enabling us to provide a higher quality of clinical care. However, there is mounting concern about developing sound clinical decision-making processes concerning these tools.
We are increasingly adding technologies to our clinical tool kits before we know which technology is most effective in a given clinical scenario. Consequently, if a test is slightly abnormal, we find ourselves ordering a series of additional tests to follow-up on the first lab test result even though there is an extremely small likelihood that the patient has a problem. Naturally, this redundancy results in added costs.
Unfortunately, I don't think anyone really knows how to solve this dilemma. Separating costs with real benefits from waste in an area like this is very complicated. Ironically, it could turn out to be true that rising imaging costs are unsustainable and also that the rising costs are creating better outcomes. At what level of quality should we stop spending? No one knows.
CC&E: Has the advent of managed care had a positive effect on our health care delivery system?
DR. SCHNEIDER: Managed care continues to surprise me. In a recent study, we found that the quality of care in the Medicare managed care plans has improved over the past 7 years. It also appears that certain aspects of managed care might have closed some of the racial disparities in quality. And there are numerous reasons to conclude that managed care has played a positive role in coordinating health care systems for patients and helping to improve clinicians' practice patterns.
On the down side, we've seen a certain amount of instability in managed care, especially in the Medicare population. As health care plans come in and out of the marketplace, they change their benefit packages, which causes confusion for beneficiaries trying to decide on a health plan.
As an aside, I think we're likely to see a similar confusion around the Medicare Part D drug benefit. Moreover, the theory that competition among health plans raises quality and controls cost may not prove true in practice. The jury is still out.
Eventually, we'll probably end up with some type of managed care style model, simply because our health care industry needs some mechanism for managing clinical delivery and financial systems. Otherwise there is no hope of controlling costs.
The question is, do we organize our managed health care model around private competing health plans, integrated delivery systems, or large physician networks that take on financial risk, or around public or government organizations? Right now, it's a mix, and it's hard to predict what form our health care industry will take in the future.
CC&E: Physicians' adherence to practice guidelines has generally been poor. Do we need guidelines to produce a universal standard of quality of care?
DR. SCHNEIDER: Practice guidelines have been a very positive force in clinical practice even though physicians, myself included, haven't always viewed them in that light.
Guidelines create a vehicle for pooling the scientific evidence and the collective intellectual resources needed to reach consensus about the most appropriate clinical practices at a given time. Guidelines need continuous updating, and the governing body that creates the guidelines has to represent a true consensus across multiple medical disciplines. If the guidelines committees disagree, then the whole process tends to have less credibility.
Guidelines also define the parameters of practice that might be considered for quality measurement. A very good example of translating guidelines into measures is ASCO's National Initiative on Cancer Care Quality (NICCQ) that created performance measures for the treatment of breast and colorectal cancer.
Although clinicians have criticized guidelines as cookbook medicine in the past, I think most of us now understand that guidelines are not a substitute for professional judgment, but rather a guide for frequently encountered clinical situations.
CC&E: Are you concerned that the rising costs of our health care delivery system will eventually prove unsustainable, leaving large gaps in care for certain populations?
DR. SCHNEIDER: I worry about that on a daily basis. As a physician, I'm constantly confronted with patients who lack health insurance, can't afford medications, can't get access to necessary testing, and even avoid care altogether because of the cost.
The impact of the rising cost of health care is already with us in the form of millions of uninsured Americans. I've heard it described as a shameful national tragedy, and I tend to agree with that view. The only way we'll ever be able to solve this devastating problem is by honestly confronting the causes of the escalating costs of health care.