Making the health care delivery system accountable - Health Care Accountability

Physician Executive, Nov-Dec, 1998 by Saul B. Wilen, Brice M. Stone

Key Concepts: Accountability/Measurement Tools/Validity Analysis/Accountability Costs

Accountability has become the fact of life for the health care provider and the delivery system. Until recently, accountability has been viewed primarily through the judicial process as issues of fraud and liability, or by managed care entities through evaluation of the financial bottom line. It is this second consideration and its ramifications that will be explored in this article. Appropriate measurement tools are needed to evaluate services, delivery, performance, customer satisfaction, and outcomes assessment. Measurement tools will be considered in light of the industry's unique considerations and realities. All participants, including insurers, employers, management, and health care providers and recipients, bear responsibilities which necessitate assessment and analysis. However, until the basic question, "Who is the customer?" is resolved, accountability issues remain complex and obscured. Accountability costs and impacts must be evaluated over time. They go way beyond bottom line cast containment an d reduction. Accountability will be accomplished when the health care industry implements quality and measurement concepts that yield the highest levels of validity and appropriateness for health care delivery.

ACCOUNTABILITY, INTERNAL AND EXTERNAL, HAS become the new fact of life. The demand for external accountability is based on the expectation that patient outcomes data from health plans will provide the yardstick by which quality can be measured. However, the concepts of quality measurement and outcomes assessment are not necessarily synonymous or mutually related. Rather, accountability requires an understanding of responsibilities, the scrutiny of services, efficacy of delivery, effective performance, customer satisfaction, and outcomes assessment, all of which are part of the accountability continuum.

Accountability goals can only be achieved by systematic evaluation of presently utilized and new measurement modalities and the circumstances under which they are applied. An understanding of their existing strengths, potentials, limitations, and weaknesses is essential, as well as a systematic analysis of their validity as predictors of value for various population/ sub-population applications. A systematic assessment of the health care delivery structure itself, Including insurers, employers, health care providers, recipients, and management with its imposed constraints enhances the perspectives necessary to apply validity analysis. The strengths should be maintained and maximized, the potentials enhanced, and the limitations must be appreciated and strongly considered in the evaluation process.

The inherent limitations of the health care delivery system are due to variables that confound the process. These include the factors posed by host variability, extent/degree of patient compliance, the frequency of complex clinical situations, sub-populations with extensive health care needs (newborns, people with chronic diseases, the elderly), wide variations, and the frequent, non-predictability of outcomes. Weaknesses in these must be corrected, and efforts made which are oriented toward creating and incorporating strategies for consistently realized positive results. Developing mechanisms for upgrading, redesigning, and retooling will help assure viability. However, throughout, we must maintain the focus--quality of life for the patient through quality health care delivery.

Driving factors

Driving the need for accountability is the cost of health care, which continues to escalate. Contributing factors are technology, an aging population, the increasing number of people with chronic health conditions, and America's reluctance to discuss rationing health care, at least for their own families.

There are approximately 37 million Americans today over age 65. In 2030, the United States Census Bureau estimates that this number will reach 68 million. (1) Individuals are no longer able to bear the entire cost of their lifetime health care. Employers, as well as the federal and state governments, are straining to keep up with the demand. The move on the part of government and managed health care companies to pay less for health care services and modalities has shifted this burden to the health care delivery industry.

The Robert Wood Johnson Foundation report, "Chronic Care in America: A 21st Century Challenge," asserts that chronic medical conditions are the major cause of illness, disability, and death in the United States today, affecting approximately 100 million Americans. The estimated cost is $475 billion, and this is expected to double by 2050. The report focuses on annual health care expenses, emphasizing that the costs for people with chronic and acute conditions averaged four times those for individuals with only acute conditions. The annual costs for individuals with more than one chronic condition increased by 41 percent per year. Chronic conditions are reported to account for 98 percent of long-term health care services, 96 percent of home care visits, 83 percent of prescription drug use, 66 percent of physician visits, and 55 percent of emergency department visits. (2)