The Uncomfortable Nexus of Money and Quality in Health Care

Are health care quality improvement efforts destined to fail for lack of objective evidence and an intensified focus on the cost of care?

The quality improvement (QI) movement has always been nascent, never really maturing to the point that it has had reliable, robust, and convincing impact for more than a few select individuals.

Over the years we've seen it measure care against this standard or that expectation. Physicians have fought back by decrying this entire approach as “cookbook medicine.” We've also seen it variation testing -- the key to understanding the "Opportunity of Reform.” Variation research can be a snapshot eye-opener that can be used to defeat the "But my patients are sicker" claim when the doctor is an outlier in his or her expenses.

In QI, the perspective is rather short-term; there's no complete "episode of care" to use as a universal standard of observation. The sickest are compared to less-sick; genetic risk is all over the map, and forget environmental differences -- too hard to measure. In other words, the quality movement has had to rely on incomplete information, often neglecting acuity or case-mix differences, the vicissitudes of life, and the absence of a real longitudinal perspective. These deficiencies are particularly noteworthy, not only in under-funded epidemiological studies -- reports that measure "process," not "outcome," quantification of "perceptions" of care as in patient satisfaction research when objective quality is being ignored -- but also in the scant objective literature on “efficiency of care,” cost-utility, or comparative statistics of health plan performance.

Now we are seeing an even bigger threat: a change in focus shifting from improving the outcomes of care (specifically, the health of patients) to establishing a business case for its quality -- in other words “how to obtain a greatest return for an investment.”

In most industries, improving the quality of the product saves money (eg, more bang for the buck). According to Dr. John Ovretveit, "Although there are some examples in the literature to support the concept that better quality of care is less expensive, few studies have produced information that could be generalized across time and institutional settings. Indeed, it is the rare article that actually includes measurement of cost or expenditures in a study that attempts to improve quality."

Of course, many decision makers in health care and insurance organizations speak about working this “nexus of quality and cost” but the information derived from such activities is not generally in the public domain. For more on this topic, read "The End of the Quality Improvement Movement; Long Live Improving Value,” published in JAMA by Robert H. Brook, MD, ScD,

Additional Reading:

Is healthcare a right or a privilege? The debate goes on, but many physicians think that it is.