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INTRODUCTION

What is “quality”? Back in the 1970s, it meant avoiding negative patient outcomes such as death, disease, disability, discomfort, and dissatisfaction. More recently, quality has meant achievement of positive objectives such as care consistent with knowledge, maximization of the quality of life, maximization of duration of life, achievement of desired health outcomes, and maximization of population health.1

There is no single, agreed-upon definition of quality. As noted in Chapter 5, it is a construct with multiple dimensions on which different stakeholders place different emphases. Chapter 5 introduced the reader to the plethora of quality measures that providers are subjected to and held accountable for. These include Donabedian’s structure, process, and outcome measures; the STEEEP measures advocated by the Institute of Medicine (IOM); the Healthcare Effectiveness Data and Information Set (HEDIS) measures used by health plans; the 4,456 measures listed by Agency for Healthcare Research and Quality (AHRQ); and the 2,266 measures listed by the Centers for Medicare and Medicaid Services (CMS) in its Inventory Tool, of which 788 have been implemented or finalized for use in a CMS program. Chapter 2 described the “murky relationships” among these quality measures, as well as between the angles of the iron triangle (eg, cost and quality). These observations set the stage for this chapter: the challenge of managing quality when “quality” is a multidimensional vector of measures that may not be highly correlated with one another. You can build an entire career working in this area.

QUALITY MANAGEMENT VERSUS MEDICAL MANAGEMENT

Before proceeding, it is important to distinguish 2 terms that are easily confused: quality management and medical management. Quality management includes tools that payers and providers use to inform the decisions that doctors and patients make to improve quality of care (usually focused on changes to process or outcome measures). Medical management includes tools that payers and providers use to reduce expensive types of healthcare utilization (eg, inpatient days, hospital admissions, emergency room visits). These tools include prior authorization, provider credentialing, hospitalists, disease management, case management, physician profiling, provider education, patient education, disease registries, patient-centered medical homes, and health promotion and wellness programs. Researchers suggest that medical management tools are expensive to operate and often have low payoffs; they are most efficacious when targeted narrowly to small, high-cost patient populations (eg, the top 3% of plan members who account for 47% of health plan costs).2 Quality management may help with medical management, and vice versa. This chapter focuses more on the former than the latter.

WHY THE NEED FOR QUALITY MANAGEMENT?

There is no doubt that quality of care delivered in the United States has improved over time. For example, the rate of Americans dying annually has fallen from 1 in 40 in 1900 to 1 in 140 by 2013. The number of deaths from heart disease has markedly declined from ...

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