Promoting and paying for quality care raises controversy

PROVIDING BETTER quality care at lower cost has long been the Holy Grail of healthcare, but reaching this goal has been more difficult and controversial than anticipated. Quality initiatives are key to improving healthcare while reducing costs, insists Dr. Mark McClellan, administrator of the Centers for Medicare & Medicaid Services (CMS), who is launching a major demonstration program to explore new payment systems and changes in the traditional Medicare program that would lead to a higher-quality, more efficient healthcare system. MCOs have long supported quality assessment activities and are collaborating with providers, purchasers and consumers in developing performance measures and care standards to drive clinical improvement.

PAYING FOR QUALITY Amid these broader efforts, a dogfight has erupted over Medicare initiatives to reward providers that achieve certain quality goals. Critics protest that pressure to meet set standards will lead to what they call "cookbook medicine" in several CMS programs:

OFFERING ASSISTANCE In addition to financial incentives, CMS is supporting efforts by state-based Quality Improvement Organizations (QIOs) to help providers achieve quality goals. These groups assist hospitals and physicians that want to participate in pay-for-performance initiatives and other demonstrations, as well as public-private collaborations.

SLOW PROGRESS While considerable progress has been made in setting medical quality measures, such as providing flu vaccines and prenatal care, much more needs to be done, according to Carolyn Clancy, director of the Agency for Healthcare Research and Quality (AHRQ).

At a healthcare quality summit last month, Clancy unveiled AHRQ's second annual report comparing state performance in 14 health quality categories. This analysis of 2004 data from hospitals, health plans and other sources studiously avoids ranking "best" and "worst" states but describes how each state compares with national averages in the various activities.

Despite signs of improvement, Clancy lamented that progress was "still slow and sporadic" and that quality of care varies considerably across the country. The situation is frustrating, she acknowledged, because providers and plans now are familiar with best practices and know how to measure healthcare quality, but lag in translating this information into action. AHRQ is working to help states understand their strengths and weaknesses and where they need to improve.

Jill Wechsler, a veteran reporter, has been covering Capitol Hill since 1994.