Interview with Dr. Mark Chassin
Hedrick Smith: Dr. Chassin, what do people know really about quality of health care and how do they find out?
Dr. Mark Chassin: I think consumers really know actually quite little about the quality of health care. Consumers in general think that quality of health care consists of how many doctors can I choose from, how many hospitals can I choose from? But when I talk about quality of care, I mean the kind of care thats likely to improve their patients health status, consumers health outcomes. And thats the kind of quality of care that consumers know little about.
Hedrick Smith: Why?
Dr. Mark Chassin: Well, one reason that people know very little about that kind of quality of care is that there isnt very much information that they have easy access to. Another is that this is a relatively [new] field of study in both science and in practice in terms of improving it. So weve had a relatively short period of time to talk to consumers about quality of care.
I think quality has many dimensions, and the service that patients experience is certainly a part of measuring quality of care, but its only a small part. As a clinician Im equally concerned, maybe even more concerned, about the content of the care the patients receive and whether that care is really going to improve their health over the short and the long run or whether its not.
Hedrick Smith: What is so special about what New York did in this field of quality and performance?
Dr. Mark Chassin: New York State put together the first program to collect scientifically reliable and valid information on one important measure of quality. That is death following coronary bypass surgery and make it public.
What [New York] it did for the first time was to provide information to hospitals and doctors about their performance compared with their peers. And no matter how good a hospital or a doctor is in looking at his or her or their own performance you really dont know what that performance is until you see comparative information.
Hedrick Smith: Whats been the impact of New York making this data available?
Dr. Mark Chassin: The program of publishing data annually on hospital mortality and then on surgeon-specific mortality produced specific changes in specific hospital processes of care that brought down the mortality statewide over fifty percent and to the point where New York had the best performance in the country.
Hedrick Smith: What do you say to the folks who say, this isnt fair to me or my hospital. It doesnt account for how sick different patients are as they go into surgery?
Dr. Mark Chassin: My answer to the criticism that the model doesnt adequately adjust for risk is that that argument is just plain scientifically wrong. It does adequately adjust for risk. And if you look at hospitals and surgeons over time, what you see is that hospitals [and] surgeons that take the highest risk patients that are usually among the best performers year after year.
I think that the most powerful impact that these data and data like them can have is when hospitals and doctors work together to find out what the problems are behind poor performance and correct them. Thats the way to get the whole delivery system moving toward improved quality.
Hedrick Smith: Whats your reaction to doctors and hospitals now who dont want to discuss this kind of material openly?
Dr. Mark Chassin: Ive always thought that the best way for a hospital to deal with this information is to own it, to take it in, to learn as much as they can from it, and to find processes they can fix to improve the outcomes that they have. Now that is not a lesson that is easily learned. . . Theres a lot of work to be done to go behind the performance data to find exactly whats wrong and fix it. Now a lot of hospitals have been able to avoid dealing with this because they havent been at the very bottom of the list. When a hospitals at the very bottom of the list, theres a fair amount of both external and internal pressure thats generated to do something about it. But if you havent been at the very bottom, if youve been below average, just around the middle you havent typically been forced with that kind of public pressure to deal with the problem actively.
I think one of the most curious aspects of the quality problems that we face is the lack of demand on the part of the consuming public for excellence in health care, for the kind of performance that they routinely get from the air travel industry. Theres been no demand on the part of the public for performance at that level. The level of quality is really quite variable both within hospitals, between hospitals, within physician practices, and between them. So you as a consumer, youre highly likely to be the victim of a quality problem and not know it.
Hedrick Smith: How do you react to hospitals and doctors who are still saying no to the media, you cant come in, we dont want to talk to you about [that]?
Dr. Mark Chassin: I think that hospitals and doctors that dont want to deal with credible information on performance are living in the previous century. I dont think theres any substitute for a delivery system in todays health care world taking an active and strong leadership role in understanding what quality is, measuring it throughout their, the domains of their delivery system, and making information public on a proactive basis about how theyre improving. Thats got to be a major part of every health cares delivery systems mission in the year 2000.
Hedrick Smith: How important is the role of the state in terms of driving quality improvement?
Dr. Mark Chassin: The role of the state in this instance in my view is as a neutral third party to collect the data from all across the state from every hospital, to do impartial and scientifically impeccable analysis on it, and to produce the data in a publicly available form. There is no other body in my experience that can play that role. Managed care companies cant play it, employers and purchasers cant play it. I dont think the federal government can play it very well. And, in fact, the state government is in the best position; its closest to the delivery system yet its not a part of the delivery system.
Hedrick Smith: How important is the role of the state as an outside party in putting the pressure of public accountability on hospitals and doctors to improve?
Dr. Mark Chassin: The state typically has two roles to play and we play one reasonably well and that is to set a floor below which no provider can fall. Thats our basic regulatory responsibility. But that doesnt move the whole delivery system toward improving quality. And thats what the New York State Cardiac Surgery Reporting System does.
Hedrick Smith: Now this system, youve said, has had a dramatic impact on mortality rates. Why havent other states picked it up? Why hasnt it moved into other diseases?
Dr. Mark Chassin: The fact that a tremendous amount of regulatory authority is concentrated in the State Health Department is an undeniable help to this program. And that isnt the case in most other places. This kind of program also requires an enormous amount of very highly refined technical expertise coupled with clinical wisdom to oversee the program. And that combination in state government is also very unusual. And I guess the last ingredient is that this kind of intervention in the delivery system is something that is really quite foreign to most state health departments which are used to operating in solely in the domain of public health. The New York Department of Health has both delivery system oversight and public health responsibilities. So it grew this hybrid together and was able to make this change.
Hedrick Smith: Isnt there also a problem that the medical profession really wasnt all that enthusiastic about it?
Dr. Mark Chassin: I think the medical profession is a big part of the problem of why we havent seen more quality improvement across wider domains both geographically and across the domains of quality problems. I think this is a tremendous opportunity for the profession to exert leadership by owning quality as inherently a medical health care issue across the board. But that would mean owning all of the quality programs, including the rampant overuse we have in the system in addition to the underuse and the mistakes we make. And so far the medical profession has not shown any sign that its willing to do that.
Hedrick Smith: How big a problem are medical errors?
Dr. Mark Chassin: Medical errors are a tremendous problem. I think the truth is that at its best, health care in the United States is the best in the world. The problem is that very often its not at its best. And by very often I mean frequently - twenty, thirty, forty percent of the time depending on the problem that one examines. Fifty percent of people with depression are not adequately diagnosed or treated. Injuries from preventable errors due to medications, for example, occur at the rate of ten per week in the average large urban hospital. Twenty-four million Americans got antibiotics for colds in 1992 and other viral infections from which they couldnt possibly benefit and thousands were harmed.
The reason were not getting performance in health care that is as good as air travel is we havent demanded it. We dont pay health care institutions to produce excellence. We pay either health care workers to produce services or we pay them a fixed rate to take care of patients on a monthly basis or yearly basis. We havent figured out a way to pay health care to encourage excellence.
Hedrick Smith: When you say public expectations are problem number one, how can public expectations be generated if the public is uninformed?
Dr. Mark Chassin: I hope that we will see a concerted effort by not just the media but by other consumer organizations, employers, managed care plans, everybody who cares about the results of health care, in keeping up the drum beat for better information, for better performance, for documented improvement. This is going to take a long time. Its not going to happen over night and it certainly wont happen if the pressure goes away.
Hedrick Smith: Well, whats your message to doctors and hospitals?
Dr. Mark Chassin: The only place where health care quality can be improved and have the best effect on patient care is where patient care is delivered: in doctors offices, in hospitals, in clinics, in nursing homes across the country. We doctors who practice in hospitals and administrators who run these institutions across the delivery system are in the best position to measure performance and improve it. If we dont do it, it will be done to us in heavy-handed ways and in ways that will not have the greatest impact on outcome. Weve got a chance to do it now, and if we dont take advantage of it, we will deserve the results that we get.
Hedrick Smith: Why is it so important to rate hospitals on open-heart surgery as well as the surgeons?
Dr. Mark Chassin: Cardiac surgery, like many things that we do in health care, is the product of a team effort. And a surgeon in this case is a key part of the team but only one part of the team. The nurses, the anesthesiologists, the pump techs, the recovery room nurses and, and their staff are the other key ingredients, some of the other key ingredients of members of the team that all come together to produce the result of a successful procedure.
Hedrick Smith: How can somebody from the outside without the new statistics tell whether or not the changes that, that are being talked about are real and are significant?
Dr. Mark Chassin: One of the aspects of the current operation of the cardiac surgery program that actually disturbs me is the increasing lag between the time the data are collected and the time they are published. And this has become an increasing problem. Well never know what performance today is using this kind of sophisticated measurement and reporting. When I was Commissioner the lag was about twelve to eighteen months. But theres a difference between being a year behind and being four years behind.
I think its important that consumers use this information to question their doctors if theyre candidates for this procedure and if they have the time and theyre not emergent situations. If theyre being referred to a hospital that has a high mortality rate in the most recent data, have your doctor ask what has the hospital done. The doctor should know if he or she is referring patients to that hospital. The hospital should be in active engagement with those data, looking at their performance, measuring their processes, improving them, and documenting for themselves that performance has improved.
Hedrick Smith: Can we expect to get the kinds of improvements in health quality wed like to get as long as the basic culture is one of fear, secrecy in keeping it within the family?
Dr. Mark Chassin: Well I think there is a culture of fear and a culture of secrecy that inhibits quality improvement. And to some degree its justified because physicians and hospitals do get sued when bad results become publicly known. That should not inhibit organizations like hospitals and group practices and integrated delivery systems from undertaking internal improvement.
The external culture of fear is reproduced internally because we have for too long treated errors as occasions to find people to blame and punish them. You have to embrace errors and learn from them. As the saying goes, every error is a treasure because it tells you something else about how to fix the system in which it occurred. We dont do that in health care.
Hedrick Smith: Are you suggesting maybe that the Northern New England experiment is the right way to go? That is, to leave it to the medical profession to work it out internally and not publish these statistics?
Dr. Mark Chassin: I think that there are a large number of roads that will lead to quality improvement and if the environment is such that multiple institutions can get together on a private basis and do improvement and actually accomplish it, thats terrific. But I dont think that its the case in many environments that expecting, hoping, wishing for many institutions in many parts of the health care delivery system to get together and improve in that kind of collaborative way will actually be borne out. It hasnt happened yet, except in a few isolated instances. And I think [that] especially with the financial pressures and economic pressures on health care institutions to survive financially that improving quality is pretty low down on their agenda. And theyre not going to get to it without a lot of external pressure.
Hedrick Smith: In New York City would the Northern New England Collaborative Approach work?
Dr. Mark Chassin: I think the chances of the Northern New England Collaborative Approach working in New York City are about as close to zero as you could measure.
Hedrick Smith: Why?
Dr. Mark Chassin: Because there are too many instutions, they are too many egos, theres too much competition among them, theres too much worry about getting together and doing collaborative projects.
I think employers are another part of the problem. The vast majority of private employers have demanded low premiums from their agents, managed care companies, and thats what theyve gotten. They have not demanded excellence in quality. So managed care hasnt interacted with the health care system in any other way except to reduce premiums. And typically in pretty heavy-handed ways that dont really even involve managing of care but just extracting price discounts from doctors and hospitals.
Hedrick Smith: Has managed care lived up to its promise to improve quality?
Dr. Mark Chassin: Well, managed care in general has certainly not lived up to the hope or the possibility of improving quality and lowering cost. Consumers want lots of choice. The open network point of service opt out programs that has every hospital and every doctor in town in the network is least well positioned to have a beneficial impact on quality.
Hedrick Smith: David Lawrence, head of the Kaiser Health Plan, talks about competing with the market on the basis of quality as their competitive advantage. In the marketplace that you describe, can Kaiser Permanente compete on the basis of quality?
Dr. Mark Chassin: I really hope that Kaiser is successful in its goal of competing in the marketplace on quality. Right now, our marketplace does not operate to reward high-quality HMOs, hospitals, group practices; but if were going to use the market as a positive instrument for change, weve got to figure out a way to harness competition and marketplace competition in the service of improved quality. Right now the marketplace competition is around reducing cost, reducing price, and its not at all about improving quality. If we could figure out how to do that I think it would be a large part of the solution, but we havent figured it out yet.
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