1. The Quality of Medical Care in America
Don Berwick

2. Outline
We already addressed coverage. Today, we cover cost and quality.
Dimensions of quality 1
What we know about quality 2
Aggregate evaluation of quality 3
The policy landscape 4
Key point: quality is a system issue, not a personal issue.

3. Dimensions of Quality

4. Institute of Medicine: 6 measures of quality (STEEEP)
IOM, 2001

5. Ways of measuring quality
QR24, Fall 2005, Lecture 15
Ways of measuring quality
Technical expertise
Are error rates sufficiently low?
Health outcomes
Is health improved?
Patient satisfaction
Do people like receiving care?

6. Evaluating Quality Should Be Done Yes No Yes Is Done No
QR24, Fall 2005, Lecture 15
Evaluating Quality
Should Be Done Yes No Yes Is Done No

7. The Quality Ideal Should Be Done Yes No Yes ☺ Is Done No ☺
QR24, Fall 2005, Lecture 15
The Quality Ideal
Should Be Done Yes No Yes ☺ Is Done No ☺

8. QR24, Fall 2005, Lecture 15
The Quality Reality
Should Be Done Yes No Yes ☺ Overuse [Misuse] Is Done No Underuse ☺

9. What We Know About Quality

10. Overuse: Stenting (PCI)
Primary PCI (< 12 hours of a heart attack) associated with improved survival
PCI > 12 hours for heart attack patients, or for patients with stable coronary disease not associated with reduced risk of death, MI, or other major cardiovascular events
71% of stents for acute conditions  99% appropriate
29% of stents for nonacute conditions  50% appropriate; 38% unsure; 12% inappropriate

11. Stent rates vary enormously across areas – much more so than heart disease

12. Mistake 1: Overuse Should Be Done Yes No Yes ☺ Overuse Is Done No
QR24, Fall 2005, Lecture 15
Mistake 1: Overuse
Should Be Done Yes No Yes ☺ Overuse Is Done No

13. More on geographic variation
Divide areas of the country into quintiles, based on spending
McAllen, TX

14. Consequences of geographic variation
Look at risk of death for patients with similar conditions, in areas with high and low spending
 No difference

15. Why does this happen? Money – doctors earn more for doing more
Patients – my neighbor had it and is doing well
Defensive medicine
Can’t do nothing

16. Underuse: Care for Diabetics

17. Physiological implications

18. Appropriate care

19. Care Management for Diabetics
QR24, Fall 2005, Lecture 15
Care Management for Diabetics
Source: NCQA data, State of Health Care Quality, US PPO’s.

20. Share of Diabetics Receiving Recommended Care

21. QR24, Fall 2005, Lecture 15
Mistake 2: Underuse
Should Be Done Yes No Yes ☺ Overuse Is Done No Underuse

22. We Know We Can Do Better Combination of IT and people
QR24, Fall 2005, Lecture 15
We Know We Can Do Better
Combination of IT and people
Contact physicians, encourage appropriate screening
Work with patients on behavioral changes, coming in to MD

23. Why don’t doctors do this?
Money – they are not paid for it
Fragmentation – people are in and out of coverage; in and out of different insurance plans
Professionalism – It’s not what being a doctor is about

24. Misuse: Back to heart attacks
QR24, Fall 2005, Lecture 15
Misuse: Back to heart attacks
CABG Mortality by Annual Volume
CABG Volume in California and Canada

25. QR24, Fall 2005, Lecture 15
Mistake 3: Misuse
Should Be Done Yes No Yes ☺ Overuse Misuse Is Done No Underuse

26. QR24, Fall 2005, Lecture 15
Medical errors
About 3 to 4 of every 100 cases in a hospital involve an error, one-third of which are negligent
Most common error: giving patient the wrong drug.
Example: Betsy Lehman
Example: Operating on the wrong patient
Example: ER, the TV show

27. QR24, Fall 2005, Lecture 15
Medical errors
Institute of Medicine, 1999

28. Why does this occur? Money Social mission in doing more
CABG brings in money
Computer systems cost money
Social mission in doing more

29. Aggregate EvaluAtion of Quality

30. Result 1: Wasted resources
1/3 of spending not associated with improved health
Source: Berwick and Hackbarth

31. QR24, Fall 2005, Lecture 15
Result 2: Poor outcomes
Quality of care in American medicine is low (Berwick)
Not a statement about HMOs or managed care; it’s a statement about medicine as a whole.

32. How much are we underperforming?
Should the US be up here?

33. The Policy Landscape
Coverage
Costs/quality

34. Proposals address different populations
Private - employer
Income
Mix – exchange; employer; individual
Medicare
Medicaid
Age

35. The policy playing field
Consumerism
Single payer
Payment Reform
Insurance
Medical care
Medicare for all
Bring everyone into ACA;
Reorient provider payments
Premium support (aka vouchers)
High deductible health insurance
Ex: Canada
Ex: Kentucky; Massachusetts
Ex: Auto insurance
Ex: Lasik; Cell phones
1. Watch these videos before next class!
2. Also, go to and preview plans. Which plan would you choose?