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Perspectives in Biology and Medicine 46.1 (2003) 1-4
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Organizers' Introduction to the Symposium on Quality Health Care
Mark Siegler* and Richard A. Epstein†
FOR THE PAST 20 YEARS, three considerations have dominated debates about the American health care system: cost of care, access to care, and quality of care. These three factors are related to each other in complex ways. Depending on the political landscape, one or another of these concerns has emerged for a time as the dominant focus. After a decade-long unsuccessful effort to contain the cost of care, primarily by managing patients and physicians, a more recent effort has emphasized quality of care (including the elimination of mistakes and errors) as another way to control costs. In the American context, quality of care is centrally important because despite spending more per capita on health care [End Page 1] than any other country, many of our health outcomes (e.g., infant mortality and life expectancy) are inferior to those of other developed countries. Consumers are demanding better outcomes.
Quality of care is not easy to define or measure. In 1990, the Institute of Medicine defined quality of care as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (Lohr 1990). Approaches for measuring quality of care have included examining health outcomes, health care processes, and organizational structure. Since no consensus exists on how best to assess quality, no one is confident that they know how to improve it. A related question is whether improving quality will ultimately save money or require additional spending.
The papers in this issue were presented at a conference on "Quality Health Care: Can We Identify It? Can We Achieve It?" The conference, held in November 2001, was sponsored by the MacLean Center for Clinical Medical Ethics, the Law School, the John M. Olin Program in Law and Economics, and the Irving B. Harris Graduate School of Public Policy Studies at the University of Chicago. The papers focus on three general questions: (1) how good are current approaches for measuring and evaluating the quality of health care? (2) is there a business case for quality improvement (i.e., is quality improvement cost effective?); and (3) can geographic variation in health care be used to evaluate and improve quality of care?
Drs. Marshall Chin and Naoko Muramatsu's paper, "What Is the Quality of Quality of Medical Care Measures? Rashomon-Like Relativism and Real-World Applications," defends the potential usefulness of current quality of care mea-sures against critics' skepticism over their soundness and practical worth. The authors highlight quality assessment strategies that have been consistently underemphasized, including patient preferences and organizational contexts. The paper concludes that current mechanisms for measuring quality of care are sufficient for most purposes—if researchers would use them effectively. In his response, Michael Koetting notes that quality of care measures can be used for two different purposes: accountability and quality improvement. While applying such measures has proved useful in improving quality of care, Koetting notes three reasons why it is difficult to link such measures to accountability: (1) difficulty defining the unit of analysis (i.e., is it the physician or the hospital?); (2) difficulty getting a sufficient number of cases in one institution; and (3) difficulty aggregating overall performance across different clinical areas.
On the question of whether there is a business case for quality improvement, a 1993 article by David Brailer and R. Lawrence Van Horn titled "Health and the Welfare of U.S. Business," recommends treating health care "like any other important component of production." Despite such recommendations, historically there has been little incentive for providers to improve quality. Lately, however, health care providers are coming under increased pressure from both [End Page 2] sides—patients and purchasers—to focus on quality. For example, the Leapfrog Group, which is mentioned in several papers in this issue, consists of several large corporations that have joined together to use financial incentives and their purchasing power to improve health care...