As long as I can remember there has been talk about the quality of medical care. Over the past decade or two, hospitals have passed through an alphabet soup of “quality improvement” programs with remarkably little data to demonstrate sustained improvement of processes or outcomes. Community and academic ambulatory practices have been essentially absent from even that feeble process.
A variety of factors have caused this state of affairs, including confusion over the definition of quality, the cost of sustaining programs, overweening confidence in the quality of one's practice, and fear of public comparison. But possibly the most important factor of all is the absence of any tangible consequences for participating or not.
But now the convergence of several strong forces is beginning to elevate the role of quality in medical care like a storm building in the Pacific that in time causes huge waves on distant shores, and sometimes causes tsunamis that wash away the unprepared.
These forces include the following:
The release of influential studies by the Institute of Medicine: “Ensuring Quality Cancer Care” (1999), “Enhancing Data Systems for Improving the Quality of Cancer Care” (2000), and “Crossing the Quality Chasm” (2001) all pointed out the major shortcomings in the quality of care in general, and the first two of cancer care in particular (www.nationalacademies.org/publications).
These reports have prompted many substantive responses, including legislation in Congress and efforts to address the quality issue by the American Society of Clinical Oncology (see below).
Employers and payers, alarmed at the double-digit increases in the cost of care, but reluctant to deny access to necessary treatment, are focusing more and more on quality as a determinant of eligibility.
Importantly, they define quality to include “value,” i.e., cost and need, as well as medical excellence.
The Leapfrog Group, a collaboration of medical directors of many Fortune 500 companies, presses quality issues more and more for their employees. Their principles include public disclosure of performance measures.
Dr. Robert Galvin, Director of Corporate Healthcare at General Electric and a member of the Leapfrog Group, said at a recent summit meeting of the National Comprehensive Cancer Network that it wouldn't be too long before “cost and quality data will become public.”
UnitedHealth Group, the country's largest health plan, pays for bone marrow transplantation for its members only at centers of excellence that, in their view, provide both medical excellence and value; they are planning a similar program for oncology in general.
And the biggest payer of all, CMS (Medicare-Medicaid), already is applying quality measures to evaluate renal dialysis; it would be a short step to either steering patients to “quality” practices or “paying for quality,” or both. Can oncology be far behind?
In the US Congress, the Kennedy-Frist bill in the Senate entitled, “Cancer Care Quality,” uses the IOM reports to mandate the development of structures, processes, measures, and oversight for cancer care paid for by government agencies, particularly CMS.
This may lead to a “pay for quality” system and, if passed, the fee-for-service payers will surely follow.
The American Society of Clinical Oncology commissioned the Harvard School of Public Health and the Rand Corporation to assess the quality of cancer care in five metropolitan regions of the country. This study, The National Initiative in Cancer Care Quality (NICCQ), is well underway and data will soon be available.
ASCO also supports a pilot project for engaging practicing oncologists in a quality-improvement program that is designed and monitored by the participating practitioners.
The seven founding practices, called the Alpha Group, have almost completed testing the first set of questions by review of unselected charts and submitting the de-identified data online.
The results were given back to each practice showing its performance relative to the unidentified remainder of the participants. Once testing of the process is complete, ASCO plans to invite all willing volunteers to participate sometime next spring.
Finally, cancer advocacy groups have always been interested in the quality of care. They have been represented in expert quality panels, such as those at the Institute of Medicine, and have informed and educated their constituents concerning various aspects of quality care. They have become an increasingly important and potent voice for high-quality care.
So what is an oncologist to do when he or she learns that the “perfect storm” of the quality movement is gaining speed out there?
My advice? The quality movement will impact your practice—community or academic, like it or not.
If oncologists don't take leadership and participate in this arena, someone else will make decisions on what quality cancer care is and, perhaps, what third-party payers will pay for.
In short, if we don't participate in credible, data-driven systems for self-examination that promote excellence in cancer care, we may be washed away by the big waves instead of riding them.
But most of all, we should do it because the formal, systematic promotion of excellence in care in our practices is the right thing to do.