For as long as I can remember we have told ourselves that the health care priorities of the American people are access, cost and quality. However there was never a consensus as to what exactly we meant by quality, let alone how to measure it, or pay for it. The truth is that there are many ways of defining quality and our research shows that different players define quality very differently. Patients, physicians , employers, insurers, the I.O.M, hospital managers, drug companies, the NCQA, public health experts, demographers and policy wonks all focus on different indicators of quality. Clearly quality, like beauty, is in the eye of the beholder.
Patients tend to define quality as meaning affordable access to almost everything. Naturally they care about the outcomes of their own care. They tend to believe that more care is better than less. The demeanor and bedside manner of doctors and nurses, being treated with respect and courtesy, are important. They often judge hospitals the way they judge hotels; good food and a nice atrium make a difference. As Ian Morrison has written “good quality is being in a waiting room with people who have more money than you”.
The Institute of Medicine has equated quality with the avoidance of medical errors (adverse events) and patient safety , and the pursuit of ways to improve these.
Most Employers tend to equate quality with having happy , uncomplaining employees at the lowest possible cost. A minority of progressive employers , such as those who participate in the NBGH and PBGH meetings, also focus on “value” and the use of sticks and carrots to influence the behavior of their employees and pay for performance incentives to influence providers.
Insurers have focused on those things they could count and measure, often based on claims data – such as treatment and prescribing patterns and the use of generics. The concept of comparative effectiveness (or better still, cost-effectiveness) appeals to them.
Drug companies tend to equate quality with the use of brand name drugs, as opposed to generics, and high levels of compliance and adherence to drug regimens. They link quality to high levels of reimbursement for their drugs, the scale of R&D spending , innovation and a strong pipeline.
Physicians tend to define quality not just in terms of outcomes but also with having happy patients. They equate quality with access to new technology, a low hassle factor and autonomy, good ancillary services, the absence of obstacles to appropriate care and being part of a strong team.
Public health experts and demographers tend to focus on population statistics such as immunization rates, life expectancy, maternal and infant mortality rates, or deaths amenable to medical care. They are also likely to compare statistics from different countries and different segments of the population and to talk about disadvantaged groups and disparities.
Policy wonks tend to focus on the use of evidence-based-medicine, the use of practice guidelines, appropriate and inappropriate care. They advocate the use of process measures (such as the use of beta blockers for heart attack patients), intermediate outcomes measures (such as the control of blood pressure, A1C, INR and cholesterol) and “real” outcome measures including the impact of care on mortality, morbidity , disability and quality of life. Unfortunately these are surprisingly rare.
It would seem to me that almost all of these ways of defining, and where possible measuring, quality have some validity. But the different perceptions of different groups tends to promote a Tower of Babel, with each group making very different assumptions about what is important. The public ,unlike most of the other groups, tends to believe that medicine provides clear right and wrong answers and that all care should be as error free as , say, flying an airplane, if the “correct” treatments are used. They are puzzled when told that only a fraction of medical care is “evidence-based” and they assume that drugs should only be used for conditions for which they have been approved (they recoil from the concept of off-label use). Most people also believe that there is much fraud , waste and abuse in the system but only a few people believe that they themselves have received unnecessary care.
Some parts of the future are pretty certain. There will be a growing focus on quality and many more and better ways to measure it. There will be changes in reimbursement to promote better quality and to pay for better performance. Health care delivery systems will change and the health care system will evolve and keep on changing. Other things are much harder to predict. As Susan Dentzer wrote in Health Affairs, paraphrasing Ralph Waldo Emerson, “quality is not a destination but a journey”. What will the new definitions of quality be, and who will define it? How will we measure it? Will we focus more on “value” – however we define that — than on quality? How much, and how, will we use cost-effectiveness as a criterion for making decisions about care? In a world of scarce resources, cost containment and tough choices, as Mark Pauly has written: “perhaps a little less quality for a lot less money might be acceptable”.
It is clear that some improvements in quality will save money. But it must also be true that other improvements – ensuring that more people get the appropriate care – will add to the cost of care. Keeping people out of hospitals and emergency rooms will reduce spending, but keeping some people alive longer may cost more. I like the argument that the more we improve quality the less we will have to cut care. But, contradictory as it may seem, I also believe that the more we improve quality, and believe we are getting good value for our money, the more willing we will be to spend more money on care.
Humphrey Taylor is Chairman of the Harris Poll, Harris Interactive.