Medicare patients appear to be getting better care for such ailments as heart attacks, pneumonia, breast cancer, and diabetes than they did a few years ago, but the quality varies dramatically by region and state.
According to Dr. Stephen Jencks, lead author of a recent quality improvement study and director of the quality improvement group at the Centers for Medicare and Medicaid Services (CMS), the report shows a small improvement in the quality of medical services offered to America’s elderly over the past two years.
The proportion of the Medicare population receiving appropriate care increased from 69.5 percent during the period 1998-99 to 73.4 percent during the 2000-01 period. On average, states improved on 20 of 22 quality indicators.
Among the biggest gains were those made in the percentage of heart attack patients being sent home from the hospital with prescriptions for beta-blocker drugs. This figure rose on average from 72 to 79 percent. Another notable improvement was in the percentage of Medicare patients receiving pneumococcal vaccines, up from 55 percent to 65 percent.
“It’s a significant rise. It’s real. It’s not just sampling error. But, gee, we do have a long way to go,” said Jencks.
“Things are going in the right direction,” agreed Dr. Randolph Peto, medical director for quality improvement at MassPRO in Waltham, Massachusetts. MassPRO is the quality improvement organization working under a contract from CMS. “This,” adds Peto, “is one of the few national studies that can provide this amount of quality improvement information, and since the Medicare population is one of biggest patient groups out there, this is important information.”
Writing in her weekly e-newsletter, Health Policy Matters, Grace-Marie Turner, president of the Galen Institute, notes, “The Medicare program still has a long way to go to provide seniors with the reliable medical care they need and deserve.
“Quality of care improved on 20 of 22 measures of quality from 1998-1999 to 2000-2001,” Turner continued, “but still only 73.4 percent of Medicare patients received ‘appropriate care,’ according to the report. This means 26.6 percent of seniors are receiving inappropriate care.”
The Jencks report also found wide variations in the quality of care across states and regions, and acknowledged “a wide gap remains between the care that could be delivered and the care that is delivered to Medicare beneficiaries.”
The Jencks study reflected mostly fee-for-service Medicare, as opposed to managed care. Health Care News has learned a comparison of the two programs is forthcoming and may help fee-for-service arrangements adopt measures proven successful in the managed care model. Conversely, managed care may learn from the fee-for-service model.
The new study follows up on an initial report, released in 2000, that weighed in on 24 indicators of quality of care during 1998 and 1999. Those indicators measured delivery of various services known to prevent or treat heart attack, heart failure, stroke, pneumonia, breast cancer, and diabetes.
The new study looked at 22 indicators, including whether a mammogram was given every two years; for heart attack victims, whether aspirin was given within 24 hours of hospital admission; and, for pneumonia, whether antibiotics were administered within eight hours of the patient’s arrival at a hospital. Information was gleaned primarily from claim forms but also from health care consumers themselves.
Room for Improvement
In both the initial report and the new follow-up, northern states and those with smaller populations showed better performance. However, some areas of care, such as dilated retinal eye exams to prevent blindness in people with diabetes, showed no improvement even in the better-performing states.
The two measures for which states, on average, did not show improvement were the percentage of patients receiving ACE inhibitor drugs for heart failure and those having blood cultures taken before receiving antibiotics for pneumonia.
Dr. Ken Thorpe, chairman of health policy and management at Emory University, said some doctors might disagree with the so-called “standard practice” measured by the Jencks study. For example, some may not consider ACE inhibitors to be the best treatment for heart failure patients.
Southern states rated poorly in the initial study generally remained at the bottom of the rankings. States at the top of the rankings in the initial study remained there. Specifically, New Hampshire and Vermont retained No. 1 and No. 2 status, while Louisiana, 49th two years ago, dipped to worst among the states. Puerto Rico was ranked last in both reports.
Some have speculated the regions faring poorly have a greater proportion of low-income, less healthy patients, but the researchers were unwilling to make that connection, saying the reasons for the variations remain unclear.
Private Sector Steps up
Jencks points to changes implemented since the initial report issued two years ago. “On a number of issues, there has been a substantial national consciousness-raising, particularly among the physician community,” he says. “Pneumococcal vaccine and beta blockers have been particular targets.”
Quality improvement initiatives instituted by The Business Roundtable’s (BRT) Leapfrog Group have played a role in making health care better and safer. In March 2001, Health Care News reported on BRT’s launch of a free-market effort to improve the quality of health care delivered to patients across the country.
BRT’s Leapfrog Group is a growing consortium of Fortune 500 companies and other large private and public health purchasers. Leapfrog Group members provide medical benefits to more than 20 million U.S. employees, who in turn spend more than $40 billion a year on health care services.
While the Leapfrog initiative is primarily directed at the non-Medicare population, the improvements have spread across the entire health care delivery spectrum. Participating Leapfrog employers have agreed to emphasize patient safety in their purchases of health care. Among the measures employed by the Leapfrog participants are:
- Computer Physician Order Entry (CPOE). CPOE allows physicians to enter medication orders through computer-linked error prevention software. Studies show the CPOE system can reduce prescription errors in hospitals by more than 50 percent.
- Evidence-based Hospital Referral. By referring patients in need of complex medical procedures to hospitals offering the best odds of survival, health care providers can improve patient outcomes by 30 percent.
- ICU Physician Staffing. Intensive Care Units staffed by physicians with credentials in critical care medicine have been shown to reduce the risk of dying in an ICU by about 10 percent.
Research conducted by John D. Birkmeyer, MD under the auspices of the Dartmouth Medical School has confirmed the three patient safety-oriented measures improve the quality of health care. And too, quality improvement organizations like MassPRO, which contract with hospitals and physicians to raise levels of service, may also have played a positive role.
Only limited information is available on whether the quality of health care is improving. The most anecdotal evidence seems to be in statistics pointing to the quality and longevity of life. The fastest growing segment of the U.S. population is the number of Americans over age 85.
Conrad F. Meier is managing editor of Health Care News.