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From the Editor |
The Slow Pace Of Change
The pursuit of improved quality has become a more pressing priority since the Institute of Medicine (IOM) published its landmark report, Crossing the Quality Chasm: A New Health System for the Twenty-first Century. Responding to persistent and systemic shortcomings in quality, the IOM’s Committee on the Quality of Health Care in America challenged the nation to undertake major redesign of both the delivery system and the policy environment that shapes care delivery. However, since publication of this report in March 2001, major headway on this ambitious goal has come slowly and grudgingly. One reason for the slow movement is the disparate interests that divide the stakeholders involved in moving the quality needle forward. At a fundamental level, the cultures of commerce and medicine are largely ships passing in the night. Medical training inculcates physicians with the values of autonomy, professionalism (self-regulation), and rendering care to one patient at a time. The imperatives of commerce are market-based competition, affordability, and the measure of performance as gauged by the value of publicly traded stock and market share.
One of the issues that currently divides these worlds revolves around the drive by purchasers to measure the performance of providers and remunerate them according to performance. Given the vast societal investment in medical care, it’s incredible that so few ways exist for evaluating performance. Large segments of the medical profession, not too surprisingly, fear that the quest for performance measurement is just another effort on the part of purchasers to control the cost of health care rather than improve its quality.
We are publishing a variety of papers that illuminate the competing interests of different stakeholders seeking advantage as they address issues posed by poor quality, rising costs, insurance coverage, and bioterrorism. Demonstrating once again the capacity of the Internet to expedite the release of timely material, we have published three Web exclusives since our May/June 2002 issue; all were peer-reviewed and published in a matter of weeks. The most provocative of this trio is an interview that Jeff Goldsmith conducted with George Poste, who chairs the Task Force on Bioterrorism, a group that advises the Department of Defense. That interview appeared on our Web site, www.healthaffairs.org, 5 June 2002. His incisive comments bring home to readers some sobering observations about our nation’s public health infrastructure and its readiness for an emergency, whether it be a terrorist attack or an emerging viral disease. In a Web-exclusive paper posted two weeks earlier, John Holahan, Joshua Wiener, and Amy Westpfahl Lutzky take a hard look at the new fiscal challenges facing states and conclude that they may have a difficult time maintaining, much less expanding, current coverage. In a Web-only paper that reflects the changing insurance marketplace, posted 19 June 2002, Jason Lee and Laura Tollen analyze the impact on premiums of new insurance products that offer reduced benefits and increased cost sharing.
In the print journal’s lead paper, Joe Newhouse explains why a quality chasm exists, pointing out that it may always be so but that the gap could be narrowed by selective interventions. Four quality-related papers follow: a discussion of medical errors in the outpatient setting (Elizabeth Lapetina and Elizabeth Armstrong), ways to move the quality debate forward (Mark Chassin), how improvements in quality could be made by reforming health care (David Lansky), and a revisitation of the evolution of HMO plan performance (Robert Miller and Harold Luft).
Next, authors address the high cost of medical care from several standpoints. Steffie Woolhandler and David Himmelstein analyze the sources of health care financing in relation to paying for universal coverage; Benjamin Druss and colleagues discuss the most expensive medical conditions; and Anne Martin and colleagues document recent trends in state health care spending, updating the federal government’s 1991 analysis.
Given the entrepreneurial nature of the U.S. health care system, the business of health is never far from the front pages. Rob Burns and Mark Pauly take a close look at the impact of integrated delivery networks, and Robert Hurley and colleagues offer a perspective on contracting between physicians and health plans. This issue also contains a wealth of material on other subjects, including the challenges provoked by pharmacogenetics, the practice of medicine online, the status of computerized physician order entry systems in hospitals, and patients in conflict with managed care plans.
Once again I remind readers of the power of the personal story as depicted through Narrative Matters, our personal essay section that debuted three years ago. Many readers have important health care stories to tell, about themselves or family members, as providers, patients, or observers. We work closely with potential contributors who sometimes find it difficult to write in personal terms. I welcome readers’ submissions to this personal essay section, which is supported by the W.K. Kellogg Foundation.
Founding Editor
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