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MARKETWATCHProfessionalism, Regulation, And The Market: Impact On Accountability For Quality Of Care
This paper examines the interplay of professionalism, regulation, and the market in shaping accountability on the part of hospitals, physicians, and health plans. We pay particular attention to the role of accreditation. We review the development of accountability and examine its recent evolution in the context of changing information technology, consumer demands, the decline of the staff– and group-model HMO, and the reemergence of health care cost inflation. The market is emerging as the dominant influence on accountability; this development will require changes in the roles and structure of regulation, professionalism, and accreditation in assuring accountability.
In their seminal paper on accountability in health care, Ezekiel Emanuel and Linda Emanuel characterize accountability as "the procedure and process by which one party provides a justification and is held responsible for its actions by another party who has an interest in the action."1 The authors classify the sites of accountability (physicians, physician organizations, hospitals, managed care plans, and so on), the domains of accountability (competence, legal and ethical conduct, financial performance, access, public health, and community benefit), and the procedures of accountability (evaluation of adherence to specific criteria and dissemination of information about the evaluation). Finally, they describe three major strategies for achieving accountability (professionalism, regulation, and market forces). In a subsequent paper, Linda Emanuel applies the model to physicians in the domain of ethical conduct.2 This paper uses the Emanuel framework to address accountability in the domain of competence, expressed as the quality of care delivered.
Physicians and physician organizations. Professionalism, along with regulation strongly influenced or controlled by professionals, has dominated accountability in medicine to a far greater degree than in virtually any other sector of our society. Professionalism implies the mastery of a body of technical knowledge and the ability to apply that knowledge to a variety of situations by independent thought and analysis.3 In its historical form, professionalism was based on the assumption that lay persons were incapable of understanding or judging the effectiveness of the services provided, and professionals were given wide latitude in setting their own standards and norms. In medicine this power has included setting prerequisites for entry into medical school, determining the course of study in both medical school and postgraduate training, and specifying the standards for entry into and continuation in medical practice.4 Licensure. State boards of licensure, composed largely of physicians, oversee licensure of physicians. While there are processes for revoking licenses, the frequency and process for doing this vary by state. A cognitive examination and a review of whether the person graduated from an approved medical school and postgraduate program are conducted only at initial licensure. Unless the physician comes under review for some major transgression and as long as annual fees are paid, physicians have in the past been licensed for life.5 Certification. Physicians can be certified by boards composed of leaders from within the specialty itself. Certification is not a requirement for licensure but is often used by hospitals to determine scope of practice and by the public, insurers, or purchasers in their choice of physicians. Only pass/fail information is released to the public. Although recertification (usually every ten years) has been instituted by most boards, physicians who were certified before the advent of recertification were granted continued certification status for life. Regulation of physician office practice. Local zoning or other rules occasionally govern physicians’ office locations or structural elements such as sinks and bathrooms. However, few if any of these requirements relate to patient safety or quality of care. In contrast to requirements placed on hospitals, nursing homes, and other providers, neither Medicare nor private insurers have formal requirements beyond basic licensure that govern physicians’ participation in insurance programs. Finally, a few states such as California have created regulations dealing with physician groups that assume full or partial risk contracts with health maintenance organizations (HMOs). In summary, accountability for quality for physicians and physician organizations has been driven by professionalism tied to the regulatory process of licensure. Certification from within the profession has played a relatively limited role. While professionalism linked to licensure and accreditation has had its critics, it has arguably played a positive role in improving the quality of health care.6 Hospitals. Accountability for hospital quality has relied primarily on regulation and accreditation. Hospital licensure is controlled at the state level. However, the federal government, through its role as a purchaser in Medicare, has played the most prominent role in hospital accountability. The legislation that created Medicare requires that hospitals, to participate in Medicare, undergo a regulatory review by the Centers for Medicare and Medicaid Services (CMS). As an alternative, the CMS allows hospitals to participate in Medicare through "deemed status" from accreditation by a private accrediting body. Many states also allow hospital licensure to be granted based in part on achieving private accreditation. The viability of most hospitals depends on their being able to participate in Medicare, which on average pays for 40 percent of hospital bed-days. Given both the distrust of direct government oversight and the need to participate in Medicare, nearly all hospitals are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).7 The Joint Commission on Accreditation of Hospitals (JCAH), the predecessor of the JCAHO, was created in response to efforts led by the American College of Surgeons (ACS), with support from the American Medical Association (AMA), to improve quality and to give physicians a more formal voice in hospital governance. Members of these organizations and of the American Hospital Association (AHA) have long made up a vast majority of the JCAH and JCAHO boards. JCAHO accreditation is based on receiving a passing score on a set of standards it promulgates. These standards also meet Medicare requirements. Although hospitals are required by the JCAHO to do quality improvement activities using measures from the Oryx measurement set, they are free to choose from among any of the more than 200 measures.8 Thus, there is no opportunity for the public to receive information on the comparative performance of hospitals. The JCAHO does, however, report several levels of accreditation status and scores on specific standards on its public Web site.9 Insurers. Before the emergence of HMOs, insurers were regulated primarily though state insurance laws. Through the 1980s accountability for HMOs, which combine insurance with varying degrees of oversight of clinical delivery functions, remained largely within an insurance regulatory framework. Accountability for those HMOs that directly provided clinical services was subject to the same licensing and accreditation standards as other providers were. Initially, there was little or no oversight for the HMO functions related to utilization or quality management or for the contractually imposed controls on physicians or other providers. In the face of these limited regulatory requirements and a lack of the history of professionalism that was associated with physicians and hospitals, HMO accountability grew largely out of market forces—specifically, pressures from purchasers for more detailed information on quality of services. One manifestation of this pressure was the creation of a voluntary accreditation process by the National Committee for Quality Assurance (NCQA).10 NCQA accreditation. NCQA accreditation has changed in important ways. First, the Health Plan Employer Data and Information Set (HEDIS) has been greatly expanded to include measures related to control of major chronic illnesses. Also, HEDIS now includes a version of the Consumer Assessment of Health Plans (CAHPS 2.0H), developed by the Agency for Healthcare Research and Quality (AHRQ). More than 80 percent of HMOs, including plans that do not opt for NCQA accreditation, now report most or all of the HEDIS measures annually to the NCQA.11 Not all measures are reported by all plans, but the population base of the plans that do report a given measure usually exceeds fifty million. Beginning in 1999 the NCQA began to incorporate performance on selected HEDIS measures as a key portion (27 percent in 2001) of the overall accreditation score. This is a major change in accreditation practice. As noted previously, nearly all accreditation and certification has relied exclusively on adherence to standards or on cognitive testing, rather than on an analysis of clinical measures of performance. A major criticism of accreditation is that there is little empirical evidence linking accreditation standards to the outcomes of the service delivered. The inclusion in accreditation of objective measures of clinical processes and outcomes of care increases the likelihood that accreditation status accurately reflects the quality of care delivered. Finally, the NCQA accreditation decision is now reported on a public Web site as excellent, commendable, accredited, provisional, or denied.12 The site also includes plan-specific information about performance on accreditation standards and HEDIS measures grouped in five categories understandable to consumers (access/service, qualified providers, staying healthy, getting better, and living with illness). The NCQA Report Card is also linked to major commercial Web sites. This level of reporting begins to provide the amount of detail that purchasers or consumers need to select health plans based on differential quality. Recognition of NCQA accreditation. While some large employers (about half of the Fortune 100) and the Office of Personnel Management (OPM) require either HEDIS reporting or accreditation or both, relatively few other employers do so. Largely because of voluntary accreditation by the NCQA and others developed before the recent move by states to increase regulation of HMOs, some states recognize private accreditation as fulfilling all or part of state HMO licensure requirements. In addition, in 2000 the CMS issued rules that will allow HMOs to substitute "deemed status" for most CMS requirements related to HMOs’ participation in the Medicare+Choice (M+C) program. However, because Medicare is a much smaller and declining proportion of HMO enrollment, Medicare requirements for HMOs, or deemed status, are likely to have a relatively small impact on accountability. Finally, there is virtually no accountability for quality beyond the market and basic state insurance regulations for non-HMO forms of managed care such as the rapidly growing preferred provider organization (PPO) market. Although the NCQA and other accreditors offer voluntary accreditation programs for PPOs, fewer than 10 percent are accredited.
Consumerism, with its demand for more and better information and for value-based purchasing of goods and services, has been relatively slow to affect medical care. Over the past decade, however, health care has begun to emerge as a focus for consumers. One driving force has been the increased availability of consumer information. Some of this information has come from purchaser groups, such as national and regional business groups on health, or from accreditors or licensing bodies. Ratings of health care organizations have also appeared in national print media, such as Newsweek, U.S. News and World Report, and Consumer Reports, and in regional publications, such as Consumers’ Checkbook. Health Web sites rank in the top three types of sites receiving the greatest number of "hits" by Web users. The explosive growth in the number of these information sites has greatly expanded the quantity and, in some instances, the quality of health care information available to the public. Although use of Web sites or print media does not prove that consumers use the information to select health plans or hospitals, a few studies have indicated that it has some impact.13 Other influences that will continue to increase the impact of the market, relative to professionalism and regulation, on accountability in health care include (1) widespread public awareness and growing concern about medical errors, with the accompanying loss of trust in traditional professionalism; (2) growing public recognition of wide variations in the use and quality of major health care technologies and services and lack of agreement about their effectiveness or appropriateness; (3) growth in choice of health care providers with the rise of alternative medicine and an increase in the types of clinicians other than physicians; (4) consumers’ demand for more choices of insurance products, leading to a rich, complex, and often fragmented set of benefits and services; (5) the reemergence of health care cost inflation, which may influence employers to increase the amount employees must pay in premiums, deductibles, or copayments, or to move to defined-contribution plans (giving employers stronger pressures to make value-based choices); and (6) the move by some HMOs (and purchasers) to base a portion of their payment or of employee copayments or deductibles on quality as well as price.14
Professionalism. Although professionalism has major limitations as the sole means of assuring accountability for quality, accountability could lose much force if professionalism were to disappear.15 In its traditional formulation, with its emphasis on physicians’ paternalism and patients’ blind trust, professionalism could be viewed as antithetical to market forces. However, the concept of professionalism is based on a social contract between the physician and the public. A new professionalism must take into account that in today’s health care system, clinicians other than physicians are included in the professional norms. The contract with the public must also include insurers, purchasers, patients, and consumers in general. Professionalism must adapt to research that has demonstrated gaps in physicians’ retention and use of critical medical knowledge. Competency evaluation as a part of professionalism must shift from a traditional reliance on physicians’ cognitive knowledge and an "assumption of quality" to an emphasis on quality improvement and performance measurement. To rebuild public trust, professionalism also must encompass the sharing of valid information with consumers, purchasers, and others. If physicians and physician organizations choose not to share information, the information the public receives may be misleading or incomplete. Although there are already online "report cards" on physicians and hospitals, many of these reports are poorly documented or rely on biased or unscientific data collection elements and methods.16 To create information that is more reliable and valid, physicians and other health care professionals must take the lead in helping to define, collect, report, and disseminate it. Professionalism, redefined and reconstituted as outlined above, could balance the growth of market forces. First steps. The barriers to professionalism’s adapting to the realities of market forces include (1) the traditional definition of professionalism; (2) a paucity of reliable and valid performance measures; (3) primitive clinical information systems; (4) physicians’ resistance to sharing information; and (5) a continued belief by many purchasers and consumers that quality is uniform. The American Board of Internal Medicine (ABIM) and the ABIM Foundation have taken important first steps to begin to redefine professionalism and to include performance measurement as part of competency evaluation.17 The primitive status of most information systems in physicians’ offices is a major barrier to creating reliable information. There are some encouraging examples of the use of electronic medical records or more extensive sharing of information between physician groups and insurers, including encounter, claims, pharmacy, and laboratory data. Organized medical groups also are leading quality improvement activities. For example, in the 1990s the specter of massive increases in malpractice premiums and technical breakthroughs, coupled with leadership by the American Society of Anesthesiology, led to widespread process improvements in anesthesiology. These improvements led to greatly reduced surgical morbidity and mortality and reduction in malpractice premiums for anesthesiologists.18 Other physician organizations, from the Society of Clinical Oncology to informal groups of cardiac surgeons in California and New England, have created effective quality improvement efforts. Reinventing professionalism. The decline in staff- and group-model HMOs and the apparent demise of the "accountable health plan" return the major responsibility for accountability in clinical practice back to physicians, physician organizations, hospitals, and other providers. If accountability is to remain primarily at the provider level and not be replaced by stronger regulation or new market-driven entities, professionalism must evolve more rapidly than in the past. Thus, the major challenge facing health care professionals is whether or not professionalism, while retaining the commitment to patients’ well-being and trust, can be reinvented to include performance-based competency, scientifically driven quality improvement, and public disclosure of valid quality information. There seems to be a clear opportunity for hospitals and physicians to regain the high ground in the quality arena by leading the movement to create more open and rigorous professionalism.19 Regulation. Traditional regulation has been erratic in its scope and has created limited evidence to suggest its effectiveness in fostering quality.20 Especially problematic has been the lack of coordination of regulation at the federal, state, and private-sector levels. This has resulted in multiple, often competing or even contrary, demands on hospitals and physicians. Moreover, regulation and legislation frequently lag well behind the dynamic forces of the health care market, as for example the recent spate of "patients’ rights" bills at a time when HMO have improved their practices and their influence is in decline.21 While there have been attempts to create regulations that are more responsive to consumerism, there has been no concerted effort to examine current regulations in light of the evolution of the health care market and its forces. Licensure changes. Licensure as a form of regulation has changed very little in response to the evolution of the health care market. Although most states now license a broad array of health care providers, there are still many restrictions on practice that reduce competition more than they protect the public. In addition, current licensing provisions provide little information of value to consumers. Some state boards of practice have been reconstituted to include a larger number of nonphysician members and are subject to oversight by legislative committees or inquiries. In addition, a few states have moved to disclosure of some sanctioning information. Continuing education as a way of improving practice has been shown repeatedly to be relatively ineffective by itself in improving quality of care.22 Given that good clinical practice is based on national, rather than state or local, norms and that legitimate use of telemedicine and Web-based medical practice is increasing, there seems to be little reason to restrict medical practice and limit competition through state-based licensure. In response, the Federation of State Medical Boards has begun work on creating "national licensure" that would still retain a role for the states but allow practice across state lines. Although there has been little movement toward relicensure requirements beyond payment of a fee (and a few states that require continuing medical education), Canada and Great Britain have begun to deliberate this issue. Regulation in public programs. In the area of regulations related to conditions of participation in government programs, the CMS and the OPM (the latter oversees the Federal Employees Health Benefits Program), in response to public concerns over patient safety, have issued additional patient safety requirements for hospitals. There is a growing effort by the CMS to examine the quality of care in the fee-for-service (FFS) portion of Medicare.23 In addition, both the OPM and CMS are striving to make much more information about quality available to their insured populations. The future type and level of regulatory interventions will likely depend to a large degree on how quickly and effectively other elements of accountability—the market, professionalism, and accreditation—evolve in response to consumer demands. Accreditation. One of the most important challenges to accreditation is the proliferation of new services and products and in the types of organizations providing them. For example, most of the growth in hospital revenues in the past decade has been in ambulatory and ancillary services; in fact, some hospitals now receive the majority of their income from activities other than inpatient services. Clearly, an accreditation process focused largely on inpatient standards does not address this new reality. Also, services such as disease management, mental health, and pharmacy benefits management, which were included in staff- and group-model HMOs, are now provided by contract with separate entities. Traditional accreditation that is focused on hospitals or HMOs, even if it addresses delegated functions, does not fully capture these new activities and sites. Accreditation will need to evolve quickly toward a more flexible, multi-entity, performance-based process. Accreditation also will need to address issues related to coordination and sharing of data between the increasingly fragmented entities involved in health care. Future demand for comparative information. Another force that is likely to strengthen in the future is the public demand for information that facilitates comparison of clinicians, clinical groups, hospitals, and health plans.24 Sole reliance on structural and process standards to provide one "yes/no" decision for accreditation of one entity provides only a little meaningful information. This is especially true in the hospital sector, where virtually all hospitals are accredited. Gathering information at the physician group or individual level will be even more costly and difficult than creating similar data on HMOs or hospitals. Given the costs of gathering information and lower fiscal margins of virtually all sectors of health care, accreditors and others will need to find ways to reduce the number of redundant standards and measures and thus the cost of data collection. Without this development, efforts to improve accountability at the provider level are likely to end in redundant and dysfunctional evaluations, excessive costs, and greater resistance by those being measured. Need for better data. As noted, the NCQA now includes performance measures as part of HMO accreditation and reports this information at multiple levels of accreditation performance. However, because of sampling-size restrictions, information on clinical performance measures, although measured at the physician level, cannot be reliably reported at that level. As noted, obtaining the depth and quantity of information necessary to prepare reliable, valid reports poses a formidable challenge. Accreditation cannot hope to play a central role in accountability in the future unless it can provide the public with reliable quality information. Consumers’ use of data. A number of other groups not directly tied to accreditation have created various "report cards." Most rely on consumer surveys of varying reliability or validity. Very few use random samples or have large enough sample sizes to allow valid comparisons between entities. Some larger HMOs rate providers, and even more of them furnish some basic demographic information about physicians in their clinical networks. A more sophisticated set of measures can be found in the ratings of HMOs and providers created by the Pacific Business Group on Health, which includes physician group-practice information for larger physician groups in the California market.25 Although some large purchasers can use current information on at least HMO quality as part of their purchasing decisions, most consumers feel overwhelmed by the number of sites and distrustful of conflicting report cards or ratings. The result is that consumers still rely largely on word-of-mouth information from friends, relatives, or coworkers in making health care choices. Role of enhanced information technology. Finally, the long-term hope for more effective accreditation and information about quality depends on enhancement of information technology use in health care. The wide availability of "broadband," Web-enabled data collection may eventually allow accreditation to be based on "real-time" measurement of a rich array of clinical performance measures that also can be used for quality monitoring, rather than on retrospective measures or standards. The availability of information about health care quality is clearly accelerating as market forces precipitate a sea change in health care. The credibility and success of each group that has historically played a role in measuring and disseminating information will depend upon its ability to adapt quickly and effectively to the rapid expansion and reduced cost of information acquisition and exchange. Much progress can be made if providers, accrediting bodies, and the government cooperate in providing creative new approaches to accountability in health care. These new approaches must be built on reliable and valid measurements of performance in all aspects of health care.
Greg Pawlson is executive vice-president of the National Committee for Quality Assurance (NCQA), and Margaret O’Kane is NCQA president. The authors thank Alice Gosfield (chairperson of the NCQA board), Joachim Roski, and Barry Scholl (also of the NCQA) for their help in editing and reviewing the current manuscript.
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