Committing to Improvement in All Areas of Health Care
The Commonwealth Fund Commission on a High Performance Health System's 2009 State Scorecard shows that in areas of health system performance where we as a nation have made a commitment to reporting and improving performance, we see dramatic results. Since the first State Scorecard was released in 2007, almost all states improved on several indicators of quality of hospital treatment, for example. This change reflects the influence of national consensus on a single set of measures for hospitals, public reporting of results of these measures on the federal Hospital Compare Web site, and widespread hospital participation in reporting following a policy change in which the Centers for Medicare and Medicaid (CMS) linked reporting to Medicare payment updates. Hospital quality has also been the focus of an intense collaborative improvement campaign across the nation.
By contrast, the majority of states failed to improve on multiple indicators of ambulatory care quality and access over most of the two-to-four-year trends captured by the 2007 and 2009 Scorecards. For example, there were only modest improvements seen in preventive care for adults—and this improvement was seen in only half the states. Public reporting on ambulatory care quality is currently limited to a subset of the population enrolled in certain managed care plans that voluntarily publish their results through the HEDIS measurement tools developed by the National Committee for Quality Assurance (NCQA).
Last week NCQA reported that health plan quality stagnated in 2008 after several years of steady gains on key measures. In addition, some areas of quality such as mental health treatment have been consistently lackluster (an "unacceptable level of mediocrity" according to NCQA). Disturbingly, 2008 marked the third year that quality failed to improve appreciably for Medicaid and Medicare health plans. This plateau in quality might reflect the limits of what managed care plans can achieve without integration of care delivery and support for physicians and patients in improving quality, as well as the absence of a broader commitment to public reporting and improvement by all types of health plans and greater participation in reporting by all physicians. Such reporting will enable all Americans to judge the quality of care that they receive and feel confident that their provider is committed to delivering the best care.
NCQA also examined costs of care for several chronic conditions and found "no clear indication that higher resource use produces better quality results." This echoes the State Scorecards, which found no systematic relationship between quality and cost of care at the state level. The health plans and states that achieve higher quality at lower cost offer hope that improving health care performance need not cost more.
More widespread adoption of electronic health records and electronic health information exchanges should enable more robust reporting of clinical data in the future. In the meantime there are things that can be done with existing data and tools, such as NCQA's HEDIS measures and the use of registries to track care for patients with chronic conditions. In short, we as a nation need to commit to making the improvements seen in hospital quality the norm across all areas of health care. Patients deserve nothing less.