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Crossing the Quality Chasm: A New Health System for the 21st Century
Priority conditions offer a framework for linking payment with patient needs and for designing incentives to reward quality. Alternative payment methods (e.g., fee for service or capitation) could be adapted to facilitate the delivery of care around priority conditions, consistent with the evidence base. Priority conditions could also provide a framework for purchasers to use in assessing the value of their purchases. See Chapter 8 for a detailed discussion on the relationship between payment and quality improvement.
Simplify Quality Measurement, Evaluation of Performance, and Feedback
Priority conditions improve the feasibility of quality measurement by offering a framework for the development of standards to guide the necessary data collection. At present, quality measurement for external accountability tends to focus on institutions or discrete services; there is little comparative information available for patients seeking specific care or physicians referring care. For example, a patient can obtain information on mammogram rates, but will find little information on methods of treatment or outcomes for breast care programs. Priority conditions can offer a framework for the development of core measures that address both processes and outcomes of care.
Part of the difficulty involved in obtaining such information is due to methodological barriers in measurement. The services of an individual physician are usually too small a unit for measurement of many aspects of clinical care processes and outcomes (Hofer et al., 1999). Even the typically sized medical group may be too small to provide reliable information on outcomes. Health plans may aggregate information, but clinicians are often affiliated with multiple plans. The delineation of priority conditions, the organization of services around these conditions, and the development of core sets of measures may help overcome some of these barriers to measurement.
Public- and private-sector oversight organizations are already organizing some of their activities around particular conditions. For example, the Foundation for Accountability has developed population- or condition-specific quality measurement guides related to adult asthma, alcohol misuse, breast cancer, diabetes, health status under age 65, and major depressive disorders (Foundation for Accountability, 1999a) and continues to work on quality measurement and consumer reporting approaches in the areas of child and adolescent health, coronary artery disease, end of life, and HIV/AIDS (Foundation for Accountability, 1999b). The Foundation’s model organizes comparative information about quality performance into five categories based on how consumers think about their care: the basics, staying healthy, getting better, living with illness, and changing needs.
The Joint Commission on Accreditation of Healthcare Organizations (2000) has identified five specific areas for the development of indicators to assess hospital care: acute myocardial infarction, heart failure, pneumonia, surgical procedures and complications, and pregnancy and related conditions. Accredita-