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The Value of Quality: Defining the Clinical and Economic Impact

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Keynote Founders' Award Address, by Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality

Medical Quality 2008, American College of Medical Quality Awards Luncheon, Austin, Texas, February 23, 2008


Hello, and thank you very much. It gives me great pleasure to accept the American College of Medical Quality (ACMQ) Founders' Award on behalf of the Agency for Healthcare Research and Quality (AHRQ). Anything that we have accomplished has been the direct result of the work of the many quality people who have invested their expertise in the Agency, so I cannot in good conscience accept this award without acknowledging their contributions. 

To be recognized by the College—one of the pre-eminent organizations for leadership and education in health care quality management—is quite an honor, not to mention joining a very distinguished list of previous winners that includes Don Berwick, David Brailer, Janet Corrigan, and many other extraordinary people.

ACMQ's engagement in research and evaluation and the body of knowledge the organization provides has elevated the standards in medical schools across the Nation. The scholarship program that you started last year to bring student residents with an interest in quality to this meeting is a great example of your commitment. You noticed there were few, if any, student residency programs on quality, and you decided to find a way to make a difference. This is a very insightful program on the part of ACMQ, and I congratulate the winners for earning the opportunity to be here. I also commend each one of you (residents) for your interest in quality.

The lack of educational curriculums on quality is a pretty telling indication of the lengths we have to go to fix the U.S. health care system. Improving quality is pivotal to transforming our health care system. Secretary Leavitt often frames this discussion by saying that we actually don't have a health care system. What we have is a large, robust, rapidly growing health care sector.

Millions of Americans provide health care or work in related businesses, but there is nothing that connects them to a system. It's a serious problem when you consider that health care, perhaps the most critical service, is one of the last vestiges of the paper-driven era.

Research from AHRQ's most recent National Healthcare Quality Report shows that the rate of improvement in the system in 2006 was a modest 3.1 percent. The rate of increase in spending was nearly 7 percent, according to the National Health Expenditure Accounts. The annual cost of care in this country now exceeds $2 trillion, and costs are expected to double within the next 10 years. This is not sustainable, and it's not the worst part. The worst part is we're not delivering more than $2 trillion worth of quality care. It's probably not even close.

I'm going to borrow from a recent story that compared the work we need to do on the health care system to peeling an onion. It said the onion is the right analogy for three reasons:

  • It can make you cry.
  • Every time you pull off a layer you learn more.
  • What you see from the outside is a lot different than what's on the inside.

The impending retirement of 78 million Baby Boomers (2010-2030) will exert tremendous pressure on our already challenged system. If something is not done, a lot of tears are going to be shed very soon. The average life expectancy of Baby Boomers is 30 years longer than that for people who were born at the turn of the 20th century. This is evidence of considerable improvement. We have made strides, but we have a long way to go and we're moving way too slowly.

To build on our efforts,  we need to move beyond the one-size-fits-all method of care. We need a robust system that includes capacity for rapid translation of beneficial advances or breakthroughs and for identifying and evaluating innovative strategies to improve the quality of care.

We need to analyze our capacity for:

  • Achievability: What can work under ideal circumstances for some people.
  • Reliability:  Getting it right for all patients every time the first time.
  • Quality enhancement: Translating research into improved patient care.

Some of the questions we need to ask:

  • Is clinical research arriving to the bedside as fast as it could?
  • Are we finding innovation in health care?
  • How do we create value?

Here's the vision for health care: Over the next decade or so we will have a real system in which doctors, hospitals, pharmacies, and labs will be connected electronically. Patients will have access to cost and quality comparisons on doctors and hospitals. These comparisons will be based on standards developed by the medical family. Ultimately, we will have health care competition based on value.

A revamped system will be built on four cornerstones:

  • Quality standards: Systems that collect quality of care information and define what constitutes quality health care.
  • Price standards: Aggregate claims information to enable cost comparisons between specific doctors and hospital.
  • Incentives: Rewards for those who provide and purchase high-quality and competitively priced health care.
  • Software standards: Common technical standards that allow for various products to talk to each other and exchange information securely.

The key to successful standards is consensus, not government-mandated standards, but active agreement across a wide spectrum of stakeholders about what works. We also need to engage our patients more because at the end of the day the currency of our daily work with patients is information and communication.

I believe that the recommendations we make to patients should be what the patients would recommend for themselves, if they had the necessary training and experience. This seems to be a readily attainable goal, especially with all of the resources that are available to us today.

We've got the money to peel away the layers. As I mentioned, we're spending more than $2 trillion annually. We've got the expertise. The United States has the world's finest physicians, nurses, and other health care workers. And we've got access to the latest tools, with new and better ones being developed all the time.

We need to provide motivation for doctors who may think that for them value-driven health care means more work for less money. We need to figure out how to show the business community more evidence of our pronouncements that a healthier workforce is more efficient and cost-effective. Our patients need to understand how important it is for them to ask questions of their care givers.

This is something that I take personally.  When you consider that the difference can be measured in lives saved how can it not be personal?

We now have patients who have easy and quick access to the same kinds of information that we do. At times, they know about new drugs for treating their conditions before we do. And they have expectations. To me, this spells opportunity.

More work? Possibly, but the important issue here is that this is an opportunity for all of us to work collectively to develop a system that makes the right thing the easy thing to do. And in order to do this, we must take advantage of all available lessons learned—in and outside of the health care system—as we move forward so that we can make the most of this chance to make 21st century health care an information-rich, patient-focused enterprise in a value-driven environment.

Again,  thank you very much for your acknowledgement of the work that takes place at AHRQ.  I am extremely pleased and proud to be accepting this award. It is a moment that will bring fond memories for many, many years to come.

Current as of February 2008

 

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