The Quality And Efficiency Of Medicare We suggest that the first task for Medicare reform is to improve the quality of care. We have identified three categories of unwarranted variation affecting the quality and efficiency of care supported by the Medicare program. To address these shortcomings, we propose the following goals for Medicare reform: (1) eliminate underprovision of effective care; (2) establish patient safety; (3) reduce scien- ^ tific uncertainty through outcomes research; (4) establish shared MEDICARE wiO5 decision making for preference-based treatments, chronic disease management, and end-of-life care; (5) establish accountabihty for capacity; and (6) promote conservative practice when greater care is wasteful if not harmful. The strategies described below have been demonstrated in selected specific settings to achieve these goals. • Strategies to ensure that effective care is provided and medicai errors are minimized. The organizational structure of medical care is critical in ensuring that effective care is not underused. Integrated health systems such as staff- and group-model HMOs can deliver effective care to almost all of their enrollees, although they are losing market share to less tightly structured health plans. (By contrast, HMOs that contract with individual physician groups [the “network” model] have been less successful in implementing these quahty standards.) A few exemplary organizations, working voluntarily, have developed the administrative and research infrastructure to implement “best practices” and have consequently reduced mortality and morbidity resulting from medical errors. Notable projects include the Northern New England Cardiovascular Study Group and Intermountain Health Systems.^^ Yet these examples are not common, and there is no mechanism in the Medicare program designed to reward providers that adopt these best-practice strategies. • Strategies to improve the quaiity of patient-physician deciHEALT H AFFAIR S – i 3 Februar y 200 2MEDICAR E “Shared decision making has not loeen widely implemented, perhaps because of fears about loss of autonomy and income.” sions regarding treatment for wiiicii patients’ preferences shouid piay a roie. Research on health outcomes is important to remedy significant gaps in scientific knowledge. Throughout the 1990s the Agency for Healthcare Research and Quahty (AHRQ) undertook programs that encouraged leading health care organizations to develop research programs, and, more recently, the National Institutes of Health (NIH) has supported networks of chnical trials to evaluate the outcomes of treatment options involving preferencesensitive surgery.^^ The Maine Medical Assessment Foundation has demonstrated that providers wiil respond to practice variations by participating in outcomes research.^” Many surgical procedures involve important trade-offs that should depend on patients’ preferences.^^ Shared decision making, in which decision support systems are used to provide patients with balanced information about treatment options for their specific disease, is designed to provide a ^^^^^””^ better match between patients’ preferences and the treatment they REFORM receive. It also has led to changes in the demand for intensive treatments. In most studies of shared decision making, overall surgery rates have dechned. Shared decision making has not been widely implemented, perhaps because of providers’ fears about loss of autonomy and income.
0 0 Emma Emma2018-10-17 04:25:272018-10-17 04:25:27Strategies to ensure that effective care is provided and medicai errors are minimized
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