William Roper
However, he said, the job is far from done. "Clearly, we have much further room for improvement, and it is important that we develop better methods and have the courage nationwide to put those methods into practice to measure the quality of care, and report results, so that decisions, whether national decisions or personal decisions, can drive change in the right direction."
Roper, who headed the Medicare program in the late 1980s, said that it is important that providers' pay be linked to performance. "But I would make the rewards more significant," he said. "Not just one percent, but 10 percent or more. If that penalizes the ones who have poor performance, so be it."
Reports on provider performance must be made more accessible to Americans, so that they can make choices on where to get their care, he said. "That's one of the real challenges in this area," he said, adding that he would look for ways to tell this message to the public at large because pushing aggressively for improved health care is the area that needs the most progress. "That's not really happening yet, and we need to do that. For now, this is still pretty arcane stuff."
Indeed, a recent study in Health Affairs led by HSPH Assistant Professor Ashish Jha found that in choosing hospitals, consumers in New York largely ignored publicly available "report cards" on the quality of coronary artery bypass surgeries performed in specific hospitals and by individual surgeons in that state.
In his lecture, Roper said that consumers are being forced to make more decisions concerning their own care, whether that be as a result of health savings accounts or increased co-pays and deductibles.
He questioned whether many consumers would be able to make those informed decisions. "There's a reason for skepticism in all this," he said. "The public at large isn't informed or motivated to be a full participant. For some percentage of Americans, consumer-driven health care makes a lot of sense, but they tend to be people who are reasonably well informed and sophisticated about their health care judgments. But most Americans find the health care system to be hopelessly complex. It's a real stretch to expect the average American to navigate their way through the system."
Roper now chairs the non-profit National Quality Forum (NQF), which was formed in 1998 to bring together consumers, purchasers, health care professionals, and researchers to develop measures for comparing providers, to encourage public disclosure of the results, and to urge people to make their decisions based on the publicly available data. He said that he will ask Medicare to fund the NQF.
At the University of North Carolina, efforts are being made to focus on a few specific areas for quality improvement: infection prevention, computerized ordering, and identification of patients who may be at risk for adverse events.
At the institutional level, Roper said that it is important that every employee be made to think about quality all the time. "Like Ford says, it's Job One," he said. "But that's a challenge. People are used to thinking of quality as a committee that meets on Tuesday afternoon."
One important way that quality can be improved is for hospitals to beef up their computer systems, he said. "If we had anything like the computer capacity in health care that we do in other parts of the economy, we'd be light years ahead," he said. "We're finally making some progress, but we have a lot of catching up to do."
—ML
Copyright, 2007, President and Fellows of Harvard College
