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Employers & Quality |
PROLOGUE
Employers And Health Care Quality
PROLOGUE: Employer activism and leadership were hallmarks of the campaign to control health care cost growth in the 1990s. But using purchasing power to leverage improvements in quality turns out to be a bit more difficult. Part of the problem is inherent. Quality is harder to define and measure than cost is. Reducing error and improving adherence to best practices require modifying complex system interactions that are difficult to operate on with the blunt economic instruments purchasers have at their disposal. Just as thorny are the circumstantial obstacles to influencing health care quality with market pressure. After a decade of bruising combat over spending, providers are leery of buyers’ newfound enthusiasm for the value equation. A retreat from tightly managed care and the pursuit of vertical integration have weakened the health system’s connective tissues, the very mechanisms that are needed to better coordinate the interplay of complex systems.
The papers in this section explore some of the complications that attend purchasers’ efforts to influence health care quality. Michelle Mello, David Studdert, and Troyen Brennan raise several perspicacious legal questions about the potential unintended consequences of one high-profile effort to improve quality by the large blue-chip employers in the Leapfrog Group. Noting that courts have been increasingly demanding standard-of-care rules in medical malpractice cases, Mello and her colleagues warn that aggressive plaintiffs could use new Leapfrog quality standards to widen further the scope of malpractice litigation in a way that would increase health care costs and exacerbate legalistic distortions in the medical practice environment. Their careful discussion reminds us that quality improvement theoretically represents a categorical imperative for the health system, but that in practice every specific strategy tends to entail difficult trade-offs.
The Leapfrog Group is one of about 100 employer coalitions nationally that have experimented with using various types of performance reporting to stimulate quality improvement, especially in hospitals. In a sampling of eleven communities, Ateev Mehrotra, Tom Bodenheimer, and Adams Dudley identify some of the many obstacles these efforts have encountered. Despite their common interest in better-quality care, employers and hospitals frequently disagree about the goals and methods that should be used. "The largest contributor to ambiguity about goals...was hospitals’ perceptions about employers’ commitment to cost versus quality," the authors write. "This distrust of employers’ intentions was widespread." Although some of their findings are discouraging, Mehrotra and colleagues see signs that with persistent efforts over time, both methodology and stakeholder relations may develop to a point where quality reporting can become an effective tool.
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