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Introduction to State Health Policy: A Seminar for New State Legislators
Slide Presentation by Brent C. James, M.D., M.Stat.
On April 1, 2005, Brent C. James made a presentation in a seminar entitled Introduction to State Health Policy.
This is the text version of Dr. James' slide presentation. Select to access the PowerPoint® Slides (660 KB).
Quality and Cost: What You Can't Afford to Ignore
Brent C. James, M.D, M. Stat.
Executive Director, Institute for Health Care Delivery Research
Intermountain Health Care
Salt Lake City, Utah, U.S.A.
A photo shows Brent C. James smiling.
The emergence of modern medicine
Circa 1860 to 1910:
- New high standards for clinical education.
- Strict requirements for professional licensing.
- Clinical practice founded on scientific research.
- New internal organization for hospitals.
1912: The Great Divide
"For the first time in human history, a random patient with a random disease consulting a doctor chosen at random stands a better than fifty-fifty chance of benefiting from the encounter."
Harvard Professor L Henderson
Source: Harris, Richard. A Sacred Trust. New York, New York: New American Library, 1966
Current health care is the best the world has ever seen
A few simple examples:
- From 1900 to 2000, average life expectancy at birth increased from only 49 years to almost 80 years.
- Since 1960, age-adjusted mortality from heart disease, number 1, has decreased by 56 percent, from 307.4 to 134.6 deaths per 100,000.
- Since 1950, age-adjusted mortality from stroke, number 3, has decreased by 70 percent, from 88.8 to 26.5 deaths per 100,000.
Initial life expectancy gains almost all resulted from public health initiatives: clean water, safe food, and especially widespread control of epidemic infectious disease. But since about 1960, direct disease treatment has made increasingly large contributions.
- Centers for Disease Control. Decline in deaths from heart disease and stroke; United States, 1900 to 1999. JAMA 1999;282(8):724-6, August 25.
- National Center for Health Statistics. Health, United States, 2000 with Adolescent Health Chartbook. Hyattsville, MD: U.S. Department of Health and Human Services, Center for Disease Control and Prevention, 2000; page 7. DHHS Publication Number PHS 2000-1232-1.
- U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: U.S. Government Printing Office, 1991. DHHS Publication Number PHS 91-50212.
Doctor John Wennberg
- Geography is destiny ("Who you see is what you get."*)
* Richard Deyo, M.D., M.P.H., in: Cherken, Deyo, Wheeler, Ciol. Physician variation in diagnostic testing for low back pain. Arthritis and Rheumatism 1994 January;37(1):15-22.
- There is no health care "system."
- Supplier-induced demand:
- Field of Dreams approach: Build it and they will come.
- James T Kirk: Do something, Bones! She's dying!
- Eddy: More is better: if it might work, do it.
- Chassin: enthusiasm for unproven methods.
- Boston City slash Boston University Hospital, 1998:
- Same house slash staff on both services.
- More beds slash easier access to resources on Boston University service.
- Boston University readmit rate circa 50 percent higher.
Medicare cost versus quality
On a scatter plot, the x-axis shows annual Medicare spending per beneficiary and the y-axis shows overall quality ranking, from 1 to 51. The plotted dots represent States. The overall trend is for spending per beneficiary to correlate negatively with quality ranking.
- In descending order of ranking, the States are New Hampshire, Vermont, Maine, North Dakota, Utah, Iowa, Colorado, Wisconsin, Connecticut, Minnesota, Oregon, Nebraska, Montana, Delaware, Massachusetts, Hawaii, Rhode Island, Virginia, Washington, South Dakota, Wyoming, Idaho, North Carolina, New York, Maryland, Michigan, Indiana, Missouri, Arizona, Kansas, Pennsylvania, South Carolina, Alaska, West Virginia, Nevada, New Mexico, Ohio, Tennessee, Kentucky, Florida, Alabama, New Jersey, California, Oklahoma, Illinois, Georgia, Arkansas, Texas, Mississippi, and Louisiana.
- The State with easily the least spending per beneficiary is Hawaii, at about 3,700 dollars a year, with the second least being Utah at about 4,800 dollars a year.
- States spending about 5,000 dollars a year in ascending order of spending are: Utah, New Hampshire, Oregon, Montana, South Dakota, North Dakota, Minnesota, Idaho, Iowa, Washington, Wisconsin, Maine, New Mexico, Vermont, Virginia, Arizona, and Indiana.
- States spending about 6000 dollars a year in ascending order of spending are: Kansas, Colorado, North Carolina, Nebraska, South Carolina, Ohio, Delaware, Arkansas, West Virginia, Kentucky, Wyoming, Tennessee, Alabama, Illinois, Georgia, Connecticut, Missouri, Pennsylvania, Nevada, Alaska, and Mississippi.
- States spending about 7000 dollars a year in ascending order of spending are: Rhode Island, Michigan, Oklahoma, New Jersey, Massachusetts, New York, Florida, Maryland, and California.
- The States with the most spending per beneficiary are Texas, with close to 8,000 dollars and Louisiana, at more than 8,000 dollars a year.
Source: Baker, K, and Chandra, A. Medicaid spending, the physician workforce, beneficiaries' quality of care. Health Affairs Web exclusive, April 7th, 2004; W4-184-197.
November 30, 1999:
The Institute of Medicine Committee on Quality of Health Care in America announces its first report: To Err is Human: Building a Safer Health System.
- Account for 44,000 to 98,000 deaths per year in the United States.
- More people die from medical injuries than from breast cancer or AIDS or motor vehicle accidents.
Sources: Brennan et al, New England Journal of Medicine 1991; Thomas et al, 1999
- Direct health care costs totaling 9 to 15 billion dollars per year.
Sources: Thomas et al, 1999; Johnson et al, 1992
November 20, 2003:
The Institute of Medicine Committee on Patient Safety Data Standards announces a major follow-on report: Patient Safety: Achieving a New Standard of Care.
November 20, 2003:
The Institute of Medicine Committee on Patient Safety Data Standards announces a major follow-on report: Patient Safety: Achieving a New Standard of Care.
Injuries of Commission versus Injuries of Omission
How good is American health care?
On a bar graph, the x-axis lists lengths of time post-admission for heart attack and the y-axis shows mortality rates in three types of hospitals.
- For the bars titled Major Teaching, the mortality rates were 18.7 after 30 days, 22.0 after 60 days, 24.3 after 90 days, and 45.6 after 2 years.
- For the bars titled Minor Teaching, the mortality rates were 20.3 after 30 days, 23.3 after 60 days, 25.3 after 90 days, and 45.7 after 2 years.
- For the bars titled Non-Teaching, the mortality rates were 23.3 after 30 days, 26.5 after 60 days, 28.5 after 90 days, and 50.2 after 2 years.
Source: Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000 Septembe;284(10):1256-62, r 13.
How good is American health care?
On a bar graph, the x-axis lists medications and the y-axis shows the percentages of so-called ideal patients receiving the medications in three types of hospitals.
- For the bars titled Major Teaching, the percentages were 91.2 for aspirin, 63.7 for ACE inhibitors, 48.8 for beta-blockers, and 55.5 for reperfusion.
- For the bars titled Minor Teaching, the percentages were 86.4 for aspirin, 60.0 for ACE inhibitors, 40.3 for beta-blockers, and 58.9 for reperfusion.
- For the bars titled Non-Teaching, the percentages were 81.4 for aspirin, 58.0 for ACE inhibitors, 36.4 for beta-blockers, and 55.2 for reperfusion.
Source: Allison JJ et al. Relationship of hospital teaching with quality of care and mortality for Medicare patients with acute MI. JAMA 2000 September; 284(10):1256-62.
American health care "gets it right" 50 percent of the time.
Source: McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. New England Journal of Medicine 2003 June; 348(26):2635-45.
Idea Number 1
American health care is very good, but it could be much better.
Reasons for variation and injuries
- How many factors can the human mind simultaneously balance to optimize an outcome? Alan Morris, MD.
- The complexity of modern American medicine exceeds the capacity of the unaided human mind. David Eddy, MD.
- Lack of valid clinical knowledge: poor evidence.
- Reliance on subjective judgment
- Subjective evaluation is notoriously poor across groups or over time.
- Enthusiasm for unproven methods; Mark Chassin, MD.
- If it might work, do it; David Eddy, MD, PhD.
- Quality means spare no expense; Brent James, MD, M-Stat.
Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous. Sir Cyril Chantler
- Neal G. Reducing risks in the practice of hospital general medicine. In Clinical Risk Management, 2nd edition. British Medical Journal 2001.
- Chantler, Cyril. The role and education of doctors in the delivery of health care. Lancet 1999; 353:1178-81.
Are most injuries unavoidable?
The price we pay for diseases of medical progress
- Blendon RJ, et al. Views of practicing physicians and the public on medical errors. New England Journal of Medicine 2002 December; 347(24):1933-40.
- Barr D. Hazards of modern diagnosis and therapy: the price we pay. JAMA 1955 December 10;159(115):1452-6.
- Moser RH. Diseases of medical progress. New England Journal of Medicine 1956 September;255(13):606-14.
Beta blockers at discharge
On a line graph, the x-axis shows months from January 1999 to October 2000 and the y-axis shows proportions of so-called ideal patients receiving beta blockers at discharge. Until June 1999, the line is steady at 0.57. Dotted lines cross the graph at 0.57 and at the threshold of 0.90. The proportion of treated patients rises above the threshold between June and July 1999, between November and December 1999, and between February and March 2000, after which the line never dips below the threshold again.
Specific proportions per month starting with July 1999 are 0.98, 0.95, 0.93, 0.89, 0.83, 0.90, 0.96, 0.87, 0.96, 0.98, 0.99, 0.95, 0.99, 0.95, 0.97, and 0.98. The graph also lists the numbers of ideal patients in each month starting with July 1999: 52, 93, 88, 64, 78, 105, 98, 117, 136, 128, 115, 138, 137, 140, 135, and 124.
Cardiac discharge medicines
This slide presents the percentage of cardiac patients discharged with a prescription for each of five classes of drugs before and after a change in discharge protocol.
- Beta blockers: before, 57 percent; after, 97 percent; national 2000, 41 percent.
- ACE and ARB inhibitors: before, 63 percent; after, 95 percent; national 2000, 62 percent.
- Statins: before, 75 percent; after, 91 percent; national 2000, 37 percent.
- Anti-platelet: before, 42 percent; after, 98 percent; national 2000, 70 percent.
- Wafarin; chronic A-Fib: before, 10 percent; after, 92 percent; national 2000, less than 10 percent.
A second chart presents mortality and readmission data for two cardiac conditions before and after the change in discharge protocol.
- Chronic heart failure: N equals 19, 083
- Mortality at 1 year: before: 22.7 percent, after: 17.8 percent, 331 fewer deaths.
- Readmissions within 1 year: before: 46.5 percent, after: 38.5 percent, 551 fewer readmissions.
- Ischemic heart disease: N equals 43,841
- Mortality at 1 year: before: 4.5 percent, after: 3.5 percent, 124 fewer deaths.
- Readmissions within 1 year, before: 20.4 percent, after: 17.7 percent, 336 fewer readmissions.
Total: 455, 887
Neonatal intensive care unit, NICU, admits by weeks' gestation
On a bar graph titled Deliveries without Complications, 2002 to 2003, the x-axis shows numbers of weeks of gestation and the y-axis shows percentages of NICU admissions.
The graph also lists the number of deliveries for each period. The percentages are 6.66 after 37 weeks for 8,001 deliveries, 3.36 after 38 weeks for 18,988 deliveries, 2.47 after 39 weeks for 33,185 deliveries, 2.65 after 40 weeks for 19,601 deliveries, 3.44 after 41 weeks for 4,505 deliveries, and 4.26 after 42 weeks for 258 deliveries.
Elective inductions in less than 39 weeks
On a line graph, the x-axis lists months and the y-axis shows percentages of elective inductions at less than 39 weeks gestation. The graph also lists the number of inductions for each month. The months go from January 2001 to July 2002, then the information breaks off, and then it resumes at January 2003 and continues to July 2004.
A green line marks a threshold at 10 percent from January 2001 to July 2002 and another at 5 percent from January to July 2004. The percentages in order are 26.7, 26.9, 29, 29.2, 25.3, 27.6, 20.4, 19.1, 16.5, 15.2, 8.4, 10.7, 8.1, 6.8, 5.9, 6.1, 6, 5.1, 6.3, 5.5, 5.2, 6.6, 6.3, 6, 5.3, 8.2, 5.4, 5.7, 6.6, 6.6, 7.9, 6.4, 7.6, 7.6, 4.6, 3.5, 4.5, and 5.
Unplanned c-section rates
A bar graph is titled Electively Induced Patients by Bishop's Score, January 2002 to August 2003. The x-axis shows Bishop's scores, and the y-axis shows percent c-sections. Each score has a multiparous component and a primiparous component, with exact numbers for each one listed.
- Below are the figures for multipara by Bishop's score:
- Score 1: 20 percent for 10 patients.
- Score 2: 8.2 percent for 49 patients.
- Score 3: 8.5 percent for 130 patients.
- Score 4: 3.6 percent for 274 patients.
- Score 5: 3.4 percent for 567 patients.
- Score 6: 3.9 percent for 856 patients.
- Score 7: 3.2 percent for 1,114 patients.
- Score 8: 2.4 percent for 1,266 patients.
- Score 9: 1.1 percent for 1,062 patients.
- Score 10: 0.9 percent for 737 patients.
- Score 11: 1 percent for 415 patients.
- Score 12: 0 percent for 86 patients.
- Score 13: 0 percent for 19 patients.
- Below are the figures for primipara by Bishop's score:
- Score 1: 33 percent for 18 patients.
- Score 2: 31.4 percent for 35 patients.
- Score 3: 36.1 percent for 61 patients.
- Score 4: 28.3 percent for 99 patients.
- Score 5: 17.7 percent for 164 patients.
- Score 6: 15.1 percent for 278 patients.
- Score 7: 17.6 percent for 375 patients.
- Score 8: 14.4 percent for 487 patients.
- Score 9: 14.3 percent for 453 patients.
- Score 10: 5.8 percent for 346 patients.
- Score 11: 4.5 percent for 179 patients.
- Score 12: 2.1 percent for 47 patients.
- Score 13: 0 percent for 7 patients.
Average hours in labor and delivery
A bar graph is titled Electively Induced Patients by Bishop's Score, January 2002 to August 2003. The x-axis shows Bishop's scores, and the y-axis shows hours in labor and delivery. Each score has a multiparous component and a primiparous component, with exact numbers for each one listed.
- Here are the figures for multipara by Bishop's score:
- Score 1: 12.4 hours for 10 patients.
- Score 2: 12 hours for 49 patients.
- Score 3: 10.8 hours for 130 patients.
- Score 4: 10.1 hours for 274 patients.
- Score 5: 9.2 hours for 567 patients.
- Score 6: 8.1 hours for 856 patients.
- Score 7: 7.6 hours for 1,114 patients.
- Score 8: 7.1 hours for 1,266 patients.
- Score 9: 6.4 hours for 1,062 patients.
- Score 10: 5.9 hours for 737 patients.
- Score 11: 5.5 hours for 415 patients.
- Score 12: 5.1 hours for 86 patients.
- Score 13: 4.1 hours for 19 patients.
- Here are the figures for primipara by Bishop's score:
- Score 1: 22.1 hours for 18 patients.
- Score 2: 20.7 hours for 35 patients.
- Score 3: 17.4 hours for 61 patients.
- Score 4: 15.7 hours for 99 patients.
- Score 5: 15 hours for 164 patients.
- Score 6: 13.8 hours for 278 patients.
- Score 7: 12.6 hours for 375 patients.
- Score 8: 11.6 hours for 487 patients.
- Score 9: 10.4 hours for 453 patients.
- Score 10: 9 hours for 346 patients.
- Score 11: 9 hours for 179 patients.
- Score 12: 7.5 hours for 47 patients.
- Score 13: 8.2 hours for 7 patients.
Primiparous elective inductions
On a combined line graph, the x-axis shows months from January 2003 to June 2004, the left y-axis shows numbers of patients, and the right y-axis shows percentages of all primiparous deliveries. A horizontal line at 53 patients is labeled Goal: Reduce Inappropriate Nulliparous Inductions by 50 Percent. A line labeled Bishop's Score Less than 10 provides the following numbers of patients in order: 110, 87, 119, 108, 124, 91, 107, 94, 100, 105, 118, 87, 81, 67, 57, 57, 46, and 52.
A line labeled Bishop's Score Less than 8 provides the following numbers of patients in order: 53, 53, 63, 53, 57, 45, 56, 52, 41, 52, 62, 46, 49, 35, 21, 21, 26, and 28. The percentages of all primiparous deliveries in order are 15.3, 14, 15.3, 14.5, 14.7, 11.6, 12.8, 11.8, 12.6, 12.8, 15.1, 12.1, 9.9, 8.8, 6.8, 6.5, 6, and 6.1.
Labor and delivery variable cost
On a line graph, the x-axis shows months from January 2003 to May 2004 and the y-axis shows average combined variable costs. A horizontal line at 1700 dollars is labeled Goal: Hold Increase to No More than 6.85 Percent. A line labeled Expected Maternal and Fetal Combined Variable Cost starts at 1700 dollars, increases very gradually to about 1720 in July 2003, picks up speed and reaches about 1780 in December 2003, and gets gradual again to reach about 1820 in May 2004.
A line labeled Actual Combined Variable Cost is less steady: it starts around 1630 dollars, wavers and drops to about 1570 by May 2003, wavers and has its biggest fall to about 1470 in January 2004, and remains nearly steady after that.
Well newborn bilirubin testing
A line graph is titled Newborns More than or Equal to 35 Weeks' Gestation Seen in Well Newborn Nursery, Excluding Hospitals Using Bilicheck Testing. The x-axis shows months from March 2001 to May 2004 and the y-axis shows percent tested. The line does not actually begin until January 2002, whereupon it drops from about 12 to 11 percent in February 2002 but then rebounds and does not fall significantly again. The major growth starts around August 2002, accelerating and then decelerating in November 2002. The line is just about at 100 percent by January 2003, where it basically stays.
Hour-specific Bilirubin Risk Chart for Term and Near-term Infants
On a zoned line graph, the x-axis shows ages in hours and the y-axis shows concentrations of neonatal serum bilirubin in mg over dl. Arcing lines begin at 12 hours to demarcate zones for levels of risk, with each zone prescribed a cutoff percentile and a treatment.
- NSB is neonatal serum bilirubin; TcB is transcutaneous bilirubin.
- The Low Risk Zone is cut off at the 40th percentile.
- In the Low Intermediate Risk Zone treatment begins with about 4.6 milligrams per deciliter and has a minimum of about 13.1 milligrams per deciliter after 120 hours, requiring NSB in 48 hours. A TCB may be substituted for NSB. Near exchange levels, an NSB is preferred.
- The High Intermediate Risk Zone, beginning at the 75th percentile, begins treatment with about 5.4 milligrams per deciliter and has a minimum of about 15.8 milligrams per deciliter after 120 hours, requiring NSB in 24 hours. A TCB may be substituted for NSB. Near exchange levels, an NSB is preferred. This zone also contains a warning: Consider Phototherapy if Premature or Evidence of Hemolysis.
- The High Risk Zone, beginning at the 95th percentile, begins with about 6.5 milligrams per deciliter and has a minimum of about 17.6 milligrams per deciliter after 120 hours, requiring phototherapy and NSB in 6 to 12 hours. A TCB may be substituted for NSB. Near exchange levels, an NSB is preferred.
- A box at the top of the chart says:
- NSB More than 25: Neonatology Phone Consultant; Consider Exchange Transfusion in the Healthy Term Infant.
- NSB More than 20: Consider Exchange Transfusion in the Hemolytic Term Infant or the Healthy Near-term Infant.
- Risk Factors
- Jaundice in the first 24 hours.
- Visible jaundice before the first discharge.
- Previous jaundiced sibling.
- Gestation less than or equal to 38 weeks.
- Exclusive breastfeeding.
- East Asian race.
- Bruising, cephalohematoma.
- Maternal age more than 25 years.
- Male sex.
Adapted and revised, April 2003, based on IHC data, 12=54 H; and from Bhutani VK et al, Pediatrics 1999;103:6-14; and Journal of Pediatrics, 2001;21:S76-82, 72-120 H.
Newborns with hyperbilirubinemia
On a line graph, the x-axis shows months from March 2001 to June 2004 and the y-axis shows numbers of patients. Horizontal threshold lines appear at 28 patients for 2001, at 27 for 2002, and at 15 thereafter.
A line labeled Bilirubin More than 25 Milligrams per Deciliter gives the following numbers of patients in order: 0, 1, 2, 0, 3, 3, 0, 3, 0, 2, 2, 3, 0, 2, 1, 2, 2, 1, 2, 1, 1, 1, 2, 0, 1, 0, 2, 1, 3, 0, 0, 0, 1, 0, 1, 1, 0, 0, 0, and 0.
A line labeled Bilirubin More than 19.9 Milligrams per Deciliter gives the following numbers of patients in order: 28, 26, 27, 37, 26, 32, 24, 34, 30, 16, 34, 19, 28, 22, 24, 26, 27, 32, 34, 31, 25, 17, 16, 14, 27, 20, 14, 15, 13, 15, 10, 13, 15, 12, 16, 15, 10, 21, 13, and 16.
On a line graph, the x-axis shows months from January 2000 to July 2004 and the y-axis shows proportions readmitted. The proportions in order are 0.061, 0.039, 0.034, 0.073, 0.047, 0.044, 0.081, 0.043, 0.027, 0.036, 0.045, 0.048, 0.062, 0.035, 0.036, 0.049, 0.019, 0.033, 0.029, 0.029, 0.034, 0.022, 0.045, 0.022, 0.023, 0.02, 0.044, 0.024, 0.012, 0.018, 0.025, 0.017, 0.009, 0.014, 0.009, 0.009, 0.02, 0.014, 0.01, 0.026, 0.022, 0.023, 0.021, 0.008, 0.019, 0.008, 0.016, and 0.014.
Protocols can improve care
A multidisciplinary team of health professionals
- Select a high priority care process.
- Generate an evidence-based "best practice" guideline.
- Blend the guideline into the flow of clinical work
- Physical layout.
- Measurement or information flow.
- Educational materials.
- Use the guideline as a shared baseline, with clinicians free to vary based on individual patient needs.
- Measure, learn from, and over time eliminate variation arising from professionals; retain variation arising from patients; "mass customization."
- Standardized processes with "smart cogs" that adapt to individual needs.
- That is "mass customization": efficient processes that can deal with complexity.
Idea Number 2
The health professions, and health care delivery, are changing
- From craft-based practice,
- Individual physicians, working alone, house or staff equals apprentices.
- Handcraft a customized solution for each patient.
- Based on a core ethical commitment to the patient.
- Vast personal knowledge gained from training and experience.
- To profession-based practice,
- Groups of peers, treating similar patients in a shared setting.
- Plan coordinated care delivery processes, for example, standing order sets.
- Individual clinicians adapt the plan to specific patient needs.
- Early experience shows.
- Less expensive: facility can staff, train, supply and organize to a single core process.
- Less complex, which means fewer mistakes and dropped handoffs, less conflict.
- Better patient outcomes.
Why profession-based practice?
- It produces better outcomes for our patients.
- It eliminates waste, reduces costs, and increases available resources for patient care.
- It puts the caring professions back in control of care delivery.
- It is the foundation for useful shared electronic data, an important next step in care delivery improvement.
Quality controls cost
- Mechanism: Waste
- Quality waste: quality, up; cost, down; forum, internal; potential savings, 25 to 40 percent.
- Inefficiency waste: quality, neutral; cost, down; forum, internal; potential savings, more than 50 percent.
- Mechanism: Cost-benefit: quality, up; cost, up; forum, society; potential savings, none.
Idea Number 3
Better care can be much cheaper care, if you set things up right.
I am sorry for you, young men, and women, of this generation. You will do great things. You will have great victories, and standing on our shoulders, you will see far, but you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals, a new outlook for humanity, is not given to every generation.
Sir William Osler, at the opening of the Philips Clinic in England, near the end of his career. Cited in Reid, Edith Gittings. The Great Physician: A Life of Sir William Osler. New York, NY: Oxford University Press; 1931, p. 241.
Current as of October 2005
Quality and Cost: What You Can't Afford to Ignore. Text version of a slide presentation at Introduction to State Health Policy: A Seminar for New State Legislators. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/statepolicy/jamestxt.htm
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