Assessing HCFA's Health Care Quality Improvement Program.

BACKGROUND: In 1992 the Health Care Financing Administration introduced the Health Care Quality Improvement Program (HCQIP), through which quality improvement projects are conducted in partnership with quality improvement organizations (QIOs), hospitals, health plans, or physicians. An evaluation of HCQIP began in May 1996 in response to the QIOs' request for an independent assessment of their activities. METHODOLOGY: The methodology and objectives of the evaluation were determined by an independent panel. The QIOs' full cohort of 970 HQIP projects could not be reviewed in the 10-month time frame available, but two topics were chosen: the management of warfarin or aspirin in patients with atrial fibrillation and the management of community-acquired pneumonia. FINDINGS: Analyses were limited to the 49 of the 68 projects that had progressed to the "improvement plan implemented" stage. However, only 39 of these 49 projects had information on outcomes, organization changes, and/or changes in process of care--and only 20 of the 49 had moved beyond the "improvement plan implemented" phase. Feedback of data led hospitals collaborating on improvement projects to revise or create processes of care. DISCUSSION: Although the assessment is the most comprehensive of its type to date, it should be viewed as a pilot study of some of the methods that could be incorporated in a more extensive and rigorous future evaluation of the impact of the HCQIP projects. Specific recommendations include random sampling of HCQIP projects across all clinical areas, conducting both prospective and retrospective assessments, developing uniform process and outcome program impact measures, and developing sustainable, ongoing automated data abstraction and analysis systems.

Dialogue. Quality and the bottom line. How can shareholder interests be prevented from interfering with quality care?

Market-driven, for-profit behavioral health systems put patients and investors in the same financial equation. Do shareholder profits depend on preventing patients from receiving appropriate care? Does investor greed directly increase consumer pain and suffering? Or, does the marketplace work the way one hopes: providing profits to investors in proportion to improvements in healthcare quality and affordability? Well-intentioned providers find themselves walking right through the middle of this high-stakes minefield. Should the government and the marketplace allow clinicians--and their standards of ethics and social values--to be swept away in the name of efficiency? Or does the marketplace for behavioral healthcare require government intervention through legislation and regulation to protect the interests of both patients and providers? This debate is far from over. Every reader of this journal has a vital stake in the outcome. In the following dialogue, leaders representing employers, clinicians, and managed care plans argue different positions in this debate and propose compelling solutions.