Health care reform and quality: Providers vs. policy makers

Most people are familiar with the black-and-white optical illusion that, depending on your perspective, either looks like a vase or two faces in profile. That diagram accurately describes current healthcare reform because perception is everything.

As I prepared a recent presentation on the affect healthcare reform will have on hospital and physician quality for a physician retreat, I realized that to understand this issue, we needed to understand the difference between how the policy makers view quality and how providers view quality. When I asked the physicians in the audience of their definition of quality care, the responses were not surprising:
 

• Good outcomes
• Minimal complications
• Improved or maintained patient function
• Appropriate use of evidence-based guidelines
• Complex conditions well managed

Underlying the physicians’ responses is the perception that quality is based on what they do, so it starts when the patient arrives. But how do policymakers view healthcare quality? The Institute of Medicine published Crossing the Quality Chasm in 2001 as a roadmap for improving our healthcare system. Many of the issues addressed by healthcare reform were defined in that book and have been used as a guide for policymakers during this past decade. One of the most important issues was how to define quality. The Institute of Medicine set six components for quality care:

• Safe: Avoiding injuries
• Effective: Evidenced based to achieve benefits and avoid over and under use
• Patient-centered: Respect and responsive to individual patient needs and preferences
• Efficient: Avoiding waste
• Timely: Reducing delays harmful to those who receive and give care
• Equitable: No variation in quality based on personal characteristics

The key to this framework is that improving quality from a population-based perspective is somewhat different than from a provider’s perspective. The most important component is that care must be timely and equitable. In other words, access to care is a fundamental component to quality from the policy perspective because a lack of care or delayed care is poor quality. Before we ever get to touch the patient, from the public policy perspective, quality starts with patients having timely access.

Clearly, some healthcare reform initiatives are related to the quality of care physicians provide, such as:
 

• Increased measurement and data transparency of processes and outcomes
• Reducing waste though appropriate care
• Using evidence-based medicine to improve outcomes
• Eliminating preventable outcomes

Although initiatives related to the care that physicians render are critical, I believe policymakers have put the greatest emphasis on improving access. Plans exist to increase the number of primary care providers. Such plans reduce the cost of medical education, offer payment incentives, allow flexible use of resident training program slots, and propose various delivery system models.

As providers of care, whether as individuals or as organizations, our quality programs must by not only raise the level of care we currently provide, but also address how we can meet the goal of increasing overall access for the patients who will now be able to seek our help.

Robert Marder, MD, CMSL is vice president of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.