Pasquale
Health Law
Fall 2011
Quality in Health Care
I. Quality is a central concern in health care politics and law
a. What is health?
i. Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
II. Defining the nature of quality in health care
a. Dnoabedian approach
i. Simplest Definition: Management by a physician of a clearly definable episode of illness in a given patient.
ii. Types of care:
1. Technical: the application of the science and technology of medicine, and of the other health sciences, to the management of a personal health problem.
a. Maximizing benefit w/out increasing risk: Training, is doc good at this type of operation, institutional technical qualities
2. Interpersonal: Socially defined values and norms; efficacy of delivery of information, communication
3. Amenities: Settings in which care is provided; consumers want to be comfortable, adds a social dimension
iii. Unnecessary care that causes harm, by donabedian criteria, is poor in quality, since such care that causes harm unnecessarily is not counterbalanced by any expectation of benefit.
b. Institute of Medicine:
i. Quality of care is degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent w/ current professional knowledge
ii. Quality with a social dimension
c. Effectiveness Initiative:
i. Effectiveness is rapidly becoming the test for a medical treatment or test.
ii. Effectiveness as the test; 3 premises:
1. Many current practices are ineffective/replaceable w/ cheaper substitutes
2. Physicians: Often select most $$$ treatments b/c of bias, fear of litigation, or financial incentives
3. Patients: Would often chose differently of they had info
III. Assessing quality
a. Structure, process and outcome measures of quality
i. Donabedian approach
1. Process – the primary object of assessment
2. Structure – the relatively stable characteristics of the providers of care, of the tools and resources they have at their disposal, and of the physical organization settings in which they work.
a. Structure, therefore, is relevant to quality in that it increases or decreases the probability of good performances.
3. Outcome – a change in a patient’s current and future health statuts that can be attributed to antecedent health care
b. Medical practice variation and the nature quality in medicine
i. Effective care
ii. Preference-sensitive care
iii. Supply-sensitive care
c. Clinical standards of practice
i. Berry v. Cardiology consultants, P.A.
1. Rule: An algorithm is relevant to the issue of standard of care it provides an analytical path demonstrating that a particular drug was appropriate medication and a description of an appropriate drug regimen.
2. Analysis:
a. The alorithm-essentially a chart showing the appropriate dosage and regimen for Amidoaone-was not followed by the card
ii. Expanding private insurance
1. Expanding Medicaid
2. Cost Control
3. Quality
4. Infrastructure
iii. PPACA
1. Makes significant decisions with regard to the direction of the American health care system, it leaves much to be decided by administrators and regulators (and future legislators).
iv. Quality in the PPACA
1. Supplement 11-26
2. Focus on how the PPACA will get people to follow quality life…
v. Why Reform?
1. US leads the planet in health cost (and medical errors)
2. US alone among the Western Industrial countries without national insurance
3. 16% uninsured; uninsured are sicker and die quicker
4. Affects employment: job lock
5. US ranked 37th by World Health Org
6. Some quality measures good; others (infant mortality) are near the bottom
7. Cost: 20% of GDP by 2015; family policy $13,000 (growing to $22,000); Medicare deficits looming
8. Care for the indigent? Medicaid misses 50% of poor
vi. The reform strategy
1. Create “exchanges” for individuals and small employers to pool risk & shop for insurance
2. Subsidize individuals/small employers purchase
3. Sliding scale up to 300%/400% of poverty
4. Expand Medicaid: reach ALL persons
