The quality challenge: How best to raise the bar for medical care

Medicare needs to become a leader in the health care quality movement, experts say. Will it use a carrot or a stick?

By Markian Hawryluk, AMNews staff. March 1, 2004.

There's an old riddle asking what a 300-pound gorilla eats. Anything it wants, is the answer. With Medicare playing the role of the 300-pounder in health care, policy experts are saying it needs to be a lot more discriminating in its diet.

Several quality improvement efforts have provided encouraging proof that U.S. health care could be vastly better than it is. But unless the federal government uses its massive power as a health care purchaser, provider and regulator, the health care system is unlikely to achieve widespread, meaningful change, experts say.

The government's approach might well determine whether physicians will come to the table willingly or be dragged Fay Wray-style, kicking and screaming.

The nation's health care system is too fragmented and complex to reach lofty quality goals on its own, said Stephen C. Schoenbaum, MD, senior vice president of the Commonwealth Fund. The list of players is long: more than 5,500 acute-care hospitals, 18,000 nursing homes, 800,000 physicians and myriad other health professionals, hundreds of insurers and thousands of self-insured payers.

Added to that are licensure boards and regulatory agencies in all 50 states; multiple accrediting organizations; and hundreds of professional organizations, boards and societies. Given the diversity of interests, it is unrealistic that leadership can emerge from the industry itself, he said.

"The government can organize and facilitate improvement processes, which has happened in other industries," Dr. Schoenbaum said. "And through federal leadership, it would be possible to improve to a greater degree than has already happened."