Last week we featured a couple of pieces of research addressing the shortcomings of some of the many quality improvement programs implemented in the last decade, primarily at the federal level. The Affordable Care Act reflects the perspective of the then-current administration and Congress that they knew best how to get better quality and so a variety of intrusive, burdensome and expensive programs were created with that goal. They were implemented by Health and Human Services and CMS with even more burdensome and complex regulations. As a viewpoint in the Journal of the American Medical Association points out, we have gotten basically nothing from these programs and the billions of dollars spent administering them and by providers trying to comply with them. (JAMA Article) As the authors point out, while there may be improvements in measures, those improvements were occurring and would have continued to occur without the added quality initiatives. The authors believe the failure is due to too many programs, too many measures, a lack of understanding of and focus on what really matters to improve health outcomes. They suggest refocussing on the relatively small pool of high-cost, high-need patients. In particular, they identify three sub-populations–patients near the end-of-life; frail older adults; and non-elderly patients with serious mental illness–and suggest developing specific measures relevant to these populations. That may or may not make sense.
But people have been trying to predict and manage the care of high-cost patients for a long time, with very minimal success. And we need to separate the issue of spending from improving health status, and delivering good outcomes from a health care service. Our spending problem relates largely to prices and while how much we spend on health care will undoubtedly bear some relationship to quality, research suggests the link isn’t that strong. Delivering better quality is a matter of training and attention to processes to ensure that all relevant information is considered, diagnoses are complete and accurate and the delivery of services is accomplished in an effective and careful manner. Getting people to have a better health status is largely a matter of ensuring that incentives and penalties are in place for appropriate behaviors. People who engage in poor health behaviors, especially after being offered programs to help change those behaviors, should pay the full price of those behaviors. The citizenry at large shouldn’t have to bear the costs of some individuals’ bad behaviors. The real problem here is the failure of people who seek and attain positions of power to recognize the limits of their abilities. No government program, in my judgment, is going to cause widespread improvement in quality. Meantime, putting these programs in place drives up costs and makes providers’ work lives miserable, which isn’t a recipe for better quality.