Health Care Accountability

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]

Responding to the need for lower costs, as of 1996 approximately 80 percent of working
Americans now participate in managed care plans.[3] Fifty-eight million Americans are
enrolled in HMOs. Eighty-three million more have joined other types of plans. Employers
now pay more than 80 percent of health care costs for their employees. Who will pick up
the costs for our relentlessly aging population and the care services that will be required?

Directions and considerations

Unfortunately, the primary thrust of managed care efforts seems directed solely toward
controlling costs as the response to financial accountability demands. The value of health
care delivery is rated primarily on its cost basis--a superficial and limited approach.
Defining the bottom line for such a complex, intangible product as quality health care
delivery is difficult at best. The present language of accountability comes out of business
and manufacturing, where a specific product is measurable. The measurement of the
health care product(s) is much less certain, and when quality of care becomes the issue,
existing measurement processes fall short. Evaluating cost and efforts focused on cost
containment are important, but patient care needs and interests must be considered on an
equal basis.

In addition, there are unique considerations in evaluating the health care delivery
product(s). First, there is a need to reconcile statistical conclusions based on mean and
median population data with frequent, complex, unpredictable clinical situations. The fact
that medicine/health care is only in part a science adds to measurement difficulties.
Medicine/health care is substantially dependent on dealing with complex biological
systems, the patient, each one differing in significant ways. The patient, especially if
elderly, exhibits combinations of both chronic and acute problems. Outcomes of clinical
interventions vary widely, and problems and complications are only sometimes
predictable.

As a result of these dynamics, the health care provider is placed in a position of divided
loyalties. Patient needs pull one way, while financial realities pull the other. The health care
provider is forced into the role of resource allocator. Can the health care deliverer also be
the rationer?

Tools

Measurement tools have become a necessary component to evaluate outcomes, including

productivity, functional efficiency, and cost containment. This has been mandated by the
external accountability effects of increasing public scrutiny, economic pressures on
employers, governmental regulations, third party insurance payers, and managed health
care. Validity analysis and appropriateness evaluation of these tools as applied to health
care delivery is at best in its infancy.

Evaluating validity can be applied on multiple levels (individually and in totality) to analyze
effectiveness in and through the process continuum. It entails the validity of
event/occurrence information, model and/or project design, data and data applications,
and the results. The conclusions must then be evaluated for appropriateness. Such
evaluation modalities exist and can be applied to the measurement tools, the conclusions,
and to the outcomes themselves. Appropriateness evaluation allows for the application of
appropriateness criteria to the conclusions. But first, the data and results must already
have successfully undergone validity analysis. Any correlations and predictions require
precise definitions and prospective assessment over time.

Quality of service concepts incorporate and produce evaluation accountability

parameters. Those already implemented in health care delivery are primarily borrowed
from the manufacturing industries, where they are used to streamline production. These
parameters include benchmarking, outcomes assessment and analysis, total quality
management (TQM), profiling, appropriate identification of resources, and appropriate
allocation and utilization of these resources.

Benchmarking entails having an established set of standards to which the actual results
are compared, followed by instituting the steps necessary to meet or exceed these
standards. TQM involves a procedure whereby a team studies a given occurrence, analyzes
the steps, makes changes and improvements based on the analysis, and then evaluates
the results. The goal is to create a continuous cycle of improvements and evaluations.
Profiling is based on performance evaluation with peer comparison. It includes counseling
to identify ways to improve and target feedback, followed by the development of a provider
profile on which future performance evaluations would be based. Appropriate resources
identification must include all sources (information, technology, networking, and human).
Resource identification, utilization, and allocation should, however, respond to information
and data generated internally by health care delivery experts who understand the concept
of quality health care. Dollars would then finally and appropriately follow demand and
need. However, deficient in the definition and implementation of all of these parameters is
optimal health care education for all providers and recipients, including family members
and extended caregivers.

Industry accountability initiatives

Considering accountability initiatives in four industries serve as contrasting examples:

accreditation/regulatory, higher education, manufacturing, and health care education.
They will be viewed in the context of application effectiveness, sensitivity and specificity,
and outcomes assessment incorporating conclusions that can withstand validity analysis,
appropriateness evaluation, and support predictability.

1. Accreditation/regulatory industry

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has joined

the accountability effort with the release of the first U.S. volume of validated performance
measures for health plans and networks. The JCAHO, in addition to evaluating and
accrediting health care organizations, also accredits managed care plans and networks.
This is an attempt to determine the level at which these plans are performing their job. The
measures consist of 225 performance indicators. The JCAHO initiative is a major effort and
the beginning of incorporating health outcomes data and other performance measures into
the accreditation process. JACHO will require each health care entity to have a system in
place to evaluate their performance and the quality of care delivered. It is assumed that
these plans and networks will significantly address the weak areas, resulting in
improvements.

In evaluating the health care environment with its accountability emphasis, quality
initiatives are at best complex. The human organism presents varying and unique situations
that greatly confound the appropriate data collected for analysis. Legitimate, appropriate
conclusions will require the proper collection and valid evaluation of the data and all
confounders.

The Health Care Financing Administration (HCFA) developed

new Medicare documentation requirements to be adhered to by physicians for hospital
visits, office visits, consultations, and other such services. They include more detailed
examination guidelines and measures for determining medical complexity. The goal was to
ensure "accurate" evaluation and management services. The guidelines have been in effect
since October 1997 and were mandated nationwide in January 1998. They require
substantiation of the service level and presume that something not fully documented did
not occur. Lack of substantiation assumes fraud and/or abuse and a fine of up to $10,000
per occurrence could be levied. HCFA's carriers will conduct prepayment reviews.

This initiative was advanced in the wake of the Department of Health and Human Services
Inspector General's estimation that in the previous year, 47 percent of a projected $23
billion of Medicare payments were questionable and due to documentation issues.[4] The
implementation of the evaluation and management documentation guidelines has been
put on hold for reevaluation, after widespread objections from clinical practitioners. These
guidelines are expected to surface again in the near future. Will close scrutiny be
necessary?

Antitrust guidelines developed by the Federal Trade Commission (FTC) and the Department
of Justice were released in mid 1996.[5] They allow physician networks to negotiate fee-for-
service contracts and use predetermined fee schedules after demonstrating that their
activities produce efficiencies that benefit consumers. Physician driven networks (PPOs,
IPAs) are exploring innovative ways to achieve these efficiencies. The outcomes criteria for
evaluating these efficiencies are based on time and cost savings with little emphasis on
quality health care delivery, quality of life issues, and quality of service concepts. Physician
risk sharing, most significantly financial, is incorporated in all components of this process
as the motivation for compliance. Such negatively perceived constructs can be
counterproductive to the espoused goal of quality and the rewards available for success.

2. Higher education industry

The higher education industry includes colleges, universities, university systems, and
specialty schools/institutions, both private and public. As in all industries, they have
experienced the effects of tightening budgets and limited resources to support programs
and research efforts. A reevaluation of priorities has resulted in assessing the teacher,
researcher, and employee functions, and their value to the mission of the higher
educational institution, including internal and external accountability demands.

These assessments are reviewed within the context of financial constraints and demands.
The factors of student and faculty needs and desires are at least more readily discussed.
From the student point of view are the issues of: access; meeting educational goals; the
availability of the necessary courses and programs; accomplishing the degree in a
reasonable timeframe; and the applicability of the educational experience to future
employment and success. From the faculty point of view, the issues are student
responsibilities and productivity in their educational endeavors; balancing time
commitments amongst teaching, advising, research, and speaking; faculty advancement;
and the academic quality of the educational institution and environment.

Accountability initiatives include monitoring the curriculum; student evaluation of courses;

student satisfaction; educational productivity; and successful placement of students into
graduate education and/or the work environment. The elimination of lifetime tenure in favor
of periodic review and reappointment using the information gleaned from the
accountability initiatives reinforces faculty responsibility on multiple levels.

3. Manufacturing industry

The manufacturing industry deals with the production of product(s) that have
predetermined specifications and can be directly tested throughout the production
process. This availability is markedly restricted in the health care delivery industry due to
the need for invasive sampling, the increased frequency of evaluations that would be
necessary, patient risks, and the significant financial costs.

The manufacturing product evolves concentrically from its basic form, which exhibits only
minimal features. To this is added customer perceived necessary additional components.
The next level incorporates added value, which differentiates one product from another.
The following layer adds unique components and product improvements that will induce
customers to pay more. This model easily makes the leap into the marketing industry
where the value is equated with the razzle-dazzle of the product enhancement layering
process.

The various health insurance plans and products available to employers conform to this
product enhancement progression, supplying an array of possibilities all of which promise
cost containment. Each additional component raises the overall cost just a little bit more.
This is akin to the basic automobile scenario to which can be added automatic
transmission, air conditioning, power brakes, and, for just a little bit more, bucket seats
and even an extended five-year warranty. Business and manufacturing, in particular, deal
with specific, measurable products or at least specific measurability of the individual
components making up the product(s).

It is possible and highly desirable to periodically and systematically sample and test each
individual component manufactured, as well as the intermediary and final stages of
component assembly. For example, measuring size to assure that the component fits the
specifications within the acceptable range in microns, or measuring the temperature or the
physical stress-force characteristics of the material(s) used to make that component, are
critical for the success of the product. Those components that do not meet the
specifications are discarded. This is the hallmark of manufacturing quality assurance.

Currently, there is a worldwide drive to obtain certification by the International Standards

Organization (ISO), the recognized standard of manufacturing production quality. The ISO
grants certification to manufacturing and assembly facilities. Accountability parameters
are included in this certification process and surely will be considered for transposition to
health care delivery as is suggested by JCAHO approaches, the federal
HCFA Medicare documentation guidelines for evaluation and management services, and
the FTC/Justice Department antitrust guidelines for physician network fee schedules.

The defined measurement tools work for the production and assembly phases in
manufacturing initiatives, but, all too often, a flaw in the design process and/or a
miscalculation in evaluating the market results in failure. Money-back guarantees if not
absolutely satisfied, recalls to replace a defective component, 90-day or longer limited
warrantees, and three or more year extended limited warrantees are just not available with
health care delivery products. How do we measure the validity of a patient's understanding
of health and health care processes, patient compliance factors,
and recipient expectations?

4. Health care education industry

The health care education industry focuses on the patient's care and needs, thus, the
patient drives the health care delivery system. The obvious applications in the care delivery
process are prevention, early detection, and rapid and effective intervention. These are
cost effective by definition. Quality health care is not the treatment of disease or the state
of being healthy--it is the attainment of health along with the best quality of life.
Knowledge-based care is the primary modality for accomplishing this goal. Team-based
care delivery is the operating system. Optimal educational strategies for health care
providers and recipients are the viable mechanisms. The outcomes of quality of life,
quality health care, cost effectiveness, and cost containment are definable, assessable,
and can withstand analysis. This operational concept allows for predictability.

Contrasts

In clinical therapeutics, it has long been understood that when multiple and differing
therapeutic modalities of varying efficacies are used in the treatment of a disease entity,
then none are specific or definitive. Failure rates are high. In basic terms, the definitive
approach holds as the standard for treatment until replaced. A similar construct can be
applied in evaluating today's management and the outcomes of health care services
provided. The standards used in constructing and evaluating the mechanisms for
management of health care delivery require diverse applicability. The mechanisms
themselves must also be widely applicable. However, the standards are yet to be
adequately developed and the mechanisms applied are too narrow in approach,
transposed from non-medical, non-health care delivery venues and industries, and lack
sensitivity and specificity in the health care delivery context.

These mechanisms are overly simplified and appear oriented to a sole end--controlling
cost. They include reducing the number of providers, available services, reimbursed time
and service contacts, and levels of reimbursement for the services rendered, and generally
applied universal schemas (algorithms) for providing these services. It is mandatory to
establish outcomes assessment parameters to evaluate and analyze the specific
approaches mandated by managed care companies. Accountability must also be
demanded and required from these management/managed care entities as it is from
health care delivery providers. The state of Texas has taken the first step in this direction by
legislating tort liability to managed care companies for financial decisions made and
limitations imposed that directly impact patient health care consequences and
outcomes.

The goal is care planning based on informed clinical decisions oriented toward the
effective range of predictable outcomes and the appropriate investment of diagnostic
resources. Establishing cost containment approaches throughout the health care
diagnosis-treatment continuum results from the cost effectiveness implications of
prevention, early detection, and rapid intervention. Within this context, quality factors, time
costs, and outcomes can be evaluated in light of variability, specific and general
effectiveness, and savings. Quality can be viewed as an outcome factor in the framework of
the full price of the medical care. Savings in time, effort, resources, and dollars can be
evaluated by applying full price models and manpower modeling.

The understanding of financial resource limitations, knowledge of health care delivery

operations, and mounting pressure for accountability have resulted in taking a harder look
at the way decisions are made. It is not in the best interests of quality patient care to turn
such decisions totally over to management experts. The health care provider must play a
leadership role in developing team-based decisions and care approaches to replace
hierarchical mandates that lack the hands on appreciation of emphasizing patient care
needs.

Commitment by all health care insurers, employers, and health care providers is needed,
as well as an integral understanding of the inherent responsibilities on all levels of the
quality health care delivery structure. Only when this commitment and understanding is in
place can valid, appropriate, and effective accountability be offered. Innovative and
creative approaches, the availability of alternative modalities and concepts, focusing on
information/data in much sharper ways, improved information transfer, appreciating the
need for change, optimal health care education, determining the quality of job
performance and the areas for improvement, and participating in outcomes assessment
and analysis are the viable roles.

Recipient strategies

Strategies for getting patients involved in their own health care are essential for overcoming
problems with compliance, understanding clinical risk factors, understanding variations in
clinical presentations, appropriate follow up, early clinical problem detection, and
prevention. In part, this can be stimulated by meaningful, quality interactions, and
communication between health care providers and their patients. This time investment
and its long-term rewards should be contrasted in terms of the financial savings predicted
with presently mandated limited interactions and contacts.

Efforts include reviewing the medical record with the patient and discussing suggestions
for a healthier lifestyle. Patient education needs to be more convenient, acceptable, and
accessible. Multi-media to allow patients to view educational materials and software, and
even creating a loan source for such materials produced for the layman, are stimulating
approaches.

Reinforcements consisting of check lists, medication information and interactions,

medical diagnosis and symptom overviews, dietary and activity guidelines, outlines for
early detection of side effects and complications, and the ways to access the
health/medical care provider early in the disease progression process need to be readily
available. All of these materials must reflect cultural competence so as to provide
congruence with the patient's customs, ethnic, social, and language needs. Optimal
education of family members and extended caregivers adds additional reinforcement,
allowing for the prevention and early detection of problems. The use of support groups,
when appropriate, not only adds to addressing patients' emotional needs, but also can be
an excellent source of additional information.

Conclusion

At the foundation of health care delivery accountability (internal and external) is the need
to clearly resolve the issue, Who is the customer? Is it the patient, insurers, health care and
other providers, hospitals, employers, or all of them? The historical, societal, and cultural
mandates point in only one direction, the patient. Providers must know what the customer
expects and wants. All providers will be held accountable and, therefore, they must
produce satisfaction by recipients and their families. Recipients and their families require
optimal health care education to become intelligent and appropriate consumers.

Patient care needs and interests, quality of life, and quality health care availability become
the primary objectives. By maximally focusing on meeting these objectives, cost-effective,
quality health care delivery will become the standard. Accountability is realized when the
health care system implements measurement and quality concepts that yield the highest
levels of validity and appropriateness for health care delivery.

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 cost containment and 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.