With support from the Fund, researchers Sheila Leatherman and Don Berwick, M.D., produced a set of case studies⁽²¹⁾ of organizations that mounted quality improvement efforts. The interventions rarely generated savings to the hospital or health system, even when they succeeded in improving quality and saving lives. In one example, Detroit's Henry Ford Health System used pharmacists to monitor patients with high cholesterol, an innovation that increased effective control from 53 percent of patients to 84 percent.⁽²²⁾ The extra cost of pharmaceutical monitoring was not reimbursed by insurance, however, and the potential payoff in reduced heart disease was too far in the future to benefit the organization. Similarly, Children's Hospital in San Diego cut the length of stay for hospitalized pediatric asthma patients in half by instituting a best-practice clinical protocol for physicians.⁽²³⁾ That change actually lost money for the hospital, since the state's MediCal program pays a daily rate for hospitalized patients. The investigators conclude that reimbursement methods must change if innovations to improve quality are to become widespread.

Some private purchasers have made quality a priority. The Leapfrog Group, a coalition of major employers' health benefit plans and public program purchasers, has issued quality standards and provided financial incentives for enrollees to seek care at hospitals with stronger quality records. Bridges to Excellence is a new employer initiative to reward "gold standard" care. Despite these promising developments, a Fund-supported project found that examples of "value-based purchasing" are relatively limited.⁽²⁴⁾

Public programs have also been slow to embrace measures to reward better care, but some interesting examples show the potential of using health insurance coverage to leverage quality improvement. A Fund-supported study⁽²⁵⁾ documented Rhode Island's RIte Care program for low-income children, which provides bonuses to participating managed care plans that meet quality targets. A new policy of providing coverage to women for two years post-partum has made family planning services more available and generated savings by reducing the number of births annually. Prenatal and obstetrical care has improved, lead poisoning screening has increased, and childbirth parity (births to a mother more than 18 months apart) has increased.

Medicare has also begun recently to provide bonuses to hospitals that meet quality performance targets and reduce payments to hospitals that fail to improve over a three-year period. Community health centers are participating in learning collaboratives to improve care for patients with chronic conditions such as diabetes. An evaluation, supported in part by the Fund, will examine the impact on quality, but preliminary indications show improvements in glucose control, blood pressure management, and patient self-management. The Veterans Administration has undergone a major organizational transformation focused on modern information technology and quality improvement processes; as a result, the share of patients meeting quality targets for prevention, chronic disease management, and palliative care has doubled over the past five years.⁽²⁶⁾

Private health care systems are also beginning to embrace such techniques. The Council of Accountable Physician Practices, which includes many of the nation's largest and most prestigious medical groups, totaling more than 17,000 physicians, has focused on quality, efficiency, and a culture of performance measurement, continual learning, innovation, and technology readiness. It has achieved HEDIS quality indicator scores 22 percent above the national averages for managed care plans, better financial performance, and comparable patient satisfaction.

These examples are encouraging, but they are far too isolated and their influence on the health care system has been dampened by the high cost of modern information technology and a shortage of benchmarks against which to measure the performance of individual providers. Creating systems that prompt and reward doing the right thing at the right time will take a major shift in the culture of health care delivery.