Recent draft: Challenges for Ensuring Quality Health Care

   Challenges for Ensuring Quality Health Care

There should be a national commitment to the maintenance, improvement, and measurement of high quality care. In ensuring high quality care for all Americans, a forum should be created for quality measurement and reporting. This will help in the development and implementation of efficient and coordinated strategies which would guarantee the widespread public availability of reliable and valid information on the quality of healthcare. Highlighting the potential for activities aimed at measuring steps for yielding improved healthcare, a wide-range of quality problems in the healthcare sector should be identified. There should be an approach to quality measurement and reporting which must be well coordinated nationally. It should demonstrate that quality care and reduced morbidity and mortality are as a result of the quality improvement efforts by both public and private sector. This report highlights some problems that are existing in the healthcare system and points out the strategies that have been used to increase confidence, improve quality outcomes, and reduce the costs of case. The paper also emphasizes the reasons why national efforts to improve the quality of care are necessary.

Challenges for Ensuring Quality Health Care

Confronting Quality Problems

The American healthcare is falling short in several areas including variations in misuse, underuse, and overuse of its services.


Premature deaths, additional health complications, and higher medical costs can appear when needed services are not provided. For example, according to a study undertaken on heart attack patients, there were approximately 18,000 unnecessary deaths annually as a result of 80% of the patients not receiving life-saving blocker treatment. The NCQA (National Committee for Quality Assurance) in its survey of managed plans concluded that 60% of patients aged 31 years and above and suffering from diabetes had not had their eyes examined in the previous year. In the same survey, 30% of women aged between 52 and 69 years did not go through mammogram in the past two years. The same found out that 30% of women aged between 21 and 64 had not been pap smeared for the past three years. Early screening reduces mortality, and if women are to be screened regularly, the country would save on treatments, reduce health complications on its citizens, and prevent premature deaths.


There are some services that are not necessary within a healthcare setup. They add costs and may lead to patients developing some complications that undermine their health. An example is where more than half of patients suffering from common cold have been incorrectly prescribed antibiotics. In the US alone, more than 7.5 billion dollars in excess costs is incurred as a result of overuse of antibiotics. The latter makes patients develop resistance. It has also been noted that approximately 16% of hysterectomies undertaken in the US are unnecessary.


A healthcare delivery that is erroneous may lead to higher costs being incurred on treatment of patients, deaths, delayed or missed diagnosis, and unnecessary injury. According to a study undertaken in New York State Hospital, in every 25 patients, one was injured in the care received. It was also concluded that 13.6% of these cases resulted in death. The study blamed negligence for 51% of deaths and 27% of injuries in this healthcare facility. The errors that could have been prevented contributed to approximately 180, 000 deaths in this hospital. According to the researchers who undertook this study, over 30% of the test results of Pap smear were classified incorrectly as normal.


Across the US, the practices of medicine are characterized by significant variations among regions and within communities. An example is the discharge rates of hospitals which are 49% higher in the Northeast than in the West. A patient suffering from diabetes is more likely to require eye examination in New England than in the Southern State.

The Role of Quality Measurement in Care Improvement

Consumer advocates, labor unions, healthcare professionals, private employers, health plans, health insurers, and federal and state governments have in the past decade developed strategies for measuring and improving healthcare quality. For example:

  • Data on the quality of heart bypass surgeries in every hospital in New York has been released by the New York State Department of Health. In the last 5 years, the use of these data has by 50% helped reduce mortality in bypass cases.
  • On the other hand, a Hospital in Michigan has managed to reduce complications resulting from reaction of drugs by 80%. Similarly, a quality improvement program managed to reduce by 75% adverse dug reaction associated with antibiotics. This was recorded at the LDS Hospital in Utah’s Salt Lake City.
  • An asthma program in Boston resulted into 76% and 86% emergency room visit reduction and hospital visit reduction respectively. This translated to only 468,000 hospitalizations.
  • Beta-blocker therapy has been successfully used in hospitals within Minnesota to prevent fetal heart attacks in patients. The hospitals through performance feedback and provider education have managed to prevent the fetal heart attacks by 63%.
  • Adoption and use of NIH guidelines has increased the use of a drug to prevent death by 100% among premature babies.

With reference to health plans and private employers, quality measurement and reporting has been used to inform customers and improve care. The following are examples:

  • General motors issue report cards to rate the quality of care health plans to its employees. These reports include satisfaction ratings, quality measurements, site visit reports, and accreditation reports.
  • The Pacific Business Group on Health calls for setting aside 2% of premiums received through health plans and allows these funds to be retained by only high performance plans.
  • All health plans serving the members of United Auto Workers must be accredited by NCQA.
  • Southern California’s Kaiser Permanente came up with interventions for employment interventions for members suffering from End Stage Renal Disease to help patients deal with illnesses that is life threatening and to continue working while under treatment. This, therefore, made workers under the Kaiser program maintain their employment.

Literature Review

The US is said to be the best in terms of healthcare professionals, research institutions, and academic health centers. Therefore, many Americans have access to high-quality health services. However, there is substandard quality of healthcare provided to the patients. At some point, the services given to patients are excessive and apart from increasing costs, it undermines the quality of care. On the other hand, these patients are not offered services that are effective towards reducing costs and improving health outcomes.

According to Londani et al. (2017), mortality rates for patients with heart attack can be reduced when they are put under beta blockers. This is according to the study that found out that only 20% of individuals suffering from heart attack received beta blockers despite being trusted as an effective intervention. It led to reduction of mortality by 43%. If all the patients were to receive beta blockers, mortality could have been educed even by 90% (Landoni et al., 2017).  Kaestner, Long, and Alexander (2014), on the other hand, maintains that over-prescription of antibiotics leads to microbial resistance of the drugs. It is a resistance that may cost the country more than 7.5 billion dollars annually because of the additional expenses in healthcare interventions. According to another study by Markey (2016), the rates of errors in the hospitals in the US are still unacceptable. There have been more than 180,000 needless deaths that result from preventable errors (Makary, 2016). The country is also experiencing a wide variation in medical practice. An example can be seen from the comparison between Northeast and West. The discharge rates of patients in Northeast are higher than the west by 49% (Levant, 2015)

A hospital with poor quality care will make patients sick, disabled, and developing low confidence in the healthcare sector. There is more potential for improving the nation’s quality of healthcare, and more representatives are interested in making these improvements in the healthcare system. Consumers should be provided with reliable and understandable information to help them in making crucial decisions on health care. Americans consider knowing the manner in which their health plans care for the sick members, the members who falls sick at an early age, and how the health plans will keep members healthy. Approximately 90% consider knowing how easy their health plans will make it easy to obtain the much needed care when they fall ill as well as how well the health plan will take care of the sick members. However, many Americans still have no information that can help them compare doctors, health care plan quality, and hospitals (Drummond, 2015).

Private and public purchasers also require more information about the quality of care they obtain for their dependents, employees, and other beneficiaries. This should be backed by the strategies to prove that the care is quality. As it was illustrated earlier in the report, many quality improvement programs such as report cards and other tools for measurement are under development by private purchasers to help them ensure the health care plans they are purchasing are of high quality and not only based on the benefits and costs. An example is the report card given to GTE employees to help them choose the plan based on quality and costs.

Other efforts for measuring and reporting the quality of health care provide the purchasers and consumers the information they require for obtaining quality healthcare and to enable the development of strategies for improving care. Government agencies and businesses have collaborated with healthcare providers, health plans, health insurers, labor unions, accredited organizations, and several other parties to promote these efforts. Collaboration between these representatives has always yielded success in relation to health care outcome improvement, cost reduction, and increasing confidence.  

The representatives have formulated and implemented a number of successful strategies, but there is still need for a national effort. This calls for more investments in quality measurement and reporting. However, despite the efforts being placed on measurement and reporting of health care quality, there is no availability of uniform information. The current efforts do not meet the need of users fully, and they have been termed as burdensome and duplicative on health care plans and providers among others. Therefore, there should be a national commitment to the improvement, measurement, and maintenance of high quality care for everyone across the US. Even with the successful efforts for healthcare quality improvement, there are still many gaps in the current system. In other cases, the system is considered to be redundant. There is no mechanism for sharing successful strategies and the best mechanism, which renders many purchasers without the much needed information for ensuring acquisition of healthcare on the basis of quality rather than costs.

These concerns can be addressed by creating two entities for measuring and reporting health care quality: a private sector forum for measurement and reporting of health care quality and public sector health care advisory council. The US Congress in collaboration with the legislation must come up with a quality council, which will be responsible for the development of national goals for improving quality of healthcare as well as the strategies for achieving them. A private quality forum should be developed to bring together the public and the private sector to identify measures that must be adopted by health plans across the US. This will ensure consumers are provided with consistent set of standards to assist them in choosing quality health plans.

The forums and the council are among the recommendations for improving health care quality in the United States. In this changing health care system, a patient’s bill of rights should be recommended to ensure that Americans are protected. These recommendations are based on the longstanding commitment to provide quality health care and increase access of health care. In the past few years, America has seen enactment of unprecedented Medicare reforms that extend the life of Medicare Trust Fund and the largest investment in children investment health care. Even with all these in place, access to health insurance still remains insufficient in the US, and this jeopardizes the quality of health care.

Quality forum strengthens the health care capacity to enable them evaluate and report on the quality of healthcare. It brings together the representatives from the private and public sector to join efforts with the providers, consumers, and other stakeholders to create a comprehensive plan for implementing measurement of quality, collection of data, and reporting standards. This will ensure consumers, purchasers, and providers get the information they need. It will also eliminate overlapping and duplicative demands for information from health care plans and health care providers and provide consumers and other purchasers with a common tool for making direct comparison of hospitals, health plans, physicians, and nursing homes among others. It will strengthen purchasers because they will now be speaking with a more pragmatic and unified voice on quality information needs, health care plans, accreditors, and health professionals. This will make providers more responsive to ensure they provide plans that compete not only on the basis of benefits and costs but also quality.




Evidence of Quality Problems

There are many areas where the quality of health care services is falling short in the US even if the country is considered to be the best in terms of provision of high quality health care services. In this section, some of the problems associated with quality including variation in the use of health care services, misuse of health care services, overuse of healthcare services, and underuse of healthcare services will be discussed.

Underuse of Health Care Services

Underuse of health care services can be seen where healthcare professionals fail to provide the healthcare services to the patients leading to development of unnecessary complications, premature deaths, and higher costs. The following services are effective in improving care and lowering costs:

Diabetes Care – annual eye examination should be administered on people suffering from diabetes to avoid getting blind (Pi-Sunyer, 2013). However, according to the survey undertaken by the National Committee for Quality Assurance, just 40% of diabetics aged 31 and above had their eyes examined in the previous year (Hahn, 2014).

Cervical Cancer Screening – in the past decade, there has been a decrease in the incidences of invasive cervical cancer. This decrease has been attributed to early detection efforts (Smith, 2016). According to the National Committee for Quality Assurance, more women aged between 52 and 69 in managed care plans are still not receiving mammogram (Meza, 2015). This has increased the number of females being diagnosed with cervical cancer and increased deaths resulting from the same.  

Mammograms – according to CDC, if breast cancer can be detected early enough through mammograms, the country can manage to prevent more than 40% of deaths from breast cancer. According to NCQD, more than 30% of women have never gone through mammogram (Meza, 2015; Fleischmann, 2017)

Heart Attacks – mortality can be reduced by up to 43% if beta blockers are used after heart attacks. Yet, studies have shown that very few patients receive beta blockers. According to Dr. Mark Chassin of Mount Sinai School of Medicine, the use of beta blockers can prevent approximately 18,000 deaths annually (Romley, 2014). Similarly, mortality can be reduced by using aspirin after heart attack. Studies have shown that more than a third of patients who have survived heart attack do not receive aspirin within two days of their hospitalization.

Overuse of Services

Unnecessary and excessive health care services increase the costs of health care. Patients are also placed at greater risk of acquiring complications and injuries. The following are some of the examples of services overuse:

Antibiotics – to date, more than two-thirds of patients diagnosed with severe bronchitis and more than half of patients diagnosed with cold received antibiotics, yet they offer little or no benefit to these individuals. More than 12 million prescriptions are written for cold, bronchitis, and upper respiratory tract infections during office visits. They account for one in every five antibiotics prescribed for adults. It is a clear indication of overuse of health care services which makes the government incur unnecessary health care costs, leads to development of antibiotic-resistance, and puts patients at risk of adverse drug reactions. The government spends additional 7.5 billion dollars annually because of such resistance (Hicks, 2013).

 Tympanostomy Tubes – many insertions of Tympanostomy tubes for children suffering from ear infections have been found to be inappropriate (Rosenfeld, 2013)

Hysterectomies – studies undertaken on the use of hysterectomies in several managed care plans have indicated that more than 20% are always unnecessary (Wallace, 2016)

Variation of Services

The United States is a large country with different geographical practices that cannot be catered for by patient health status differences, preferences, available resources, and clinical uncertainty. It is a variation in services that has led to disparities in morbidity and mortality.

Diabetes Care –there is a twofold variation in the routine care offered to patients diagnosed with diabetes. This includes eye examination, measurement of glycosylated hemoglobin, and measurement of total cholesterol. Similar variation is also associated with eye examination rate preferable for patients suffering from diabetes. More than a half of diabetics are under annual eye examination in managed care plans in New England as compared with South Central region of the country which has only 33% in plans (Inzucchi, 2015).

Rates of Cesarean Section – In the state hospitals in Washington, the rates of Cesarean section still range between 0 and 50%. (Betran, 2015).

Hospital services – to date, the discharge rate in hospital in Northeast is still higher than the discharge rate of hospitals in the Western states of the United States of America.

Misuse of Services

Many health care services within the US are characterized with erroneous activities, and this causes delayed or missed diagnosis, premature deaths, unnecessary injuries, and increased costs. The following are some of the evidence of services that are being misused:

Laboratory Tests – experts maintain that between 10 and 30% of Pap smear test results are not always classified as normal after screening. These are errors that have greatly contributed to delayed or missed diagnosis. At times, patients have to undergo more extensive and costly treatment because of the latter (Luyten, 2014).  

Medication Errors – from different studies, it has been noted that approximately 28% of injuries resulting from adverse reactions to prescribed drugs among non-obstetrical patients can be prevented. These injuries make the government spend more money on patients due to the duration they stay in hospitals. It is estimated that these complications may make a 700 bed hospital to incur additional 2.8 million dollars annually. The cost of the events of preventable drug adverse is approximately 2 billion dollars annually (Kaestner, Long, & Alexander, 2014).

Hospital Injuries –there are many cases where injuries have resulted from medical management rather than the disease under treatment. This has been recorded in 3.7 percent of all hospitalizations in New York. In other cases, investigators have attributed negligence as the main cause of more than 27% of deaths in American Hospitals. Prevented errors have contributed to more than 180,000 deaths annually.

Laboratory Tests –the errors associated with incorrect classification of Pap smear test results leads to missed or delayed diagnoses. This means that patients must undergo extensive and costly treatment.

Ear Infection – several studies have demonstrated that using cheaper antibiotics for treatment of ear infections will reduce the requirement for another antibiotic within 24 days of the initial therapy. It is related to reduce rates of adverse reactions of drugs and produces better results than the expensive antibiotics. However, physicians still prescribe more expensive antibiotics to their patients (Hicks, 2013).




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