ASH Panel: Hematologists/Oncologists Are Urged to Take the Initiative on Quality Control Measures to Cut Costs

NASHVILLE--Health-care costs may not yet be taking a large enoughchunk out of national expenditures to inspire drastic health-carereform, Mark Chassin, MD, said at a forum on health-care reformat the American Society of Hematology (ASH) meeting (see "ASH Panel: How many Hemotologists/Oncologists Are Enough?").

But since such reforms are inevitable, he said, hematologistsshould be taking steps now to deal with them, most notably, qualitycontrol measures.

Currently, he said, 14% of the national wealth is spent on healthcare, but medical care costs are going up at about double theaverage rate of inflation. Dr. Chassin suggested that medicalexpenditures for 1994 may reach a trillion dollars, with the secondtrillion added in about 7 years, if medical costs keep expandingat 10% a year.

"At some point on this upward curve, those costs become unsustainable,for everybody," he said.

When that occurs, he said, drastic measures to control costs willbe taken at the expense of health-care access and quality. Themeasures already being instituted--shifting costs to patientsby increasing deductibles and copayments, restricting freedomof choice--are a "blunt instrument," he said, that throwsup barriers to patients in need of care. He went so far as tosay that such cost-cutting measures are a "hazard to health."

Quality-Driven Approach

The health-reform strategy Dr. Chassin prefers is a quality-drivenapproach that has been used in New York State, where he serveduntil recently as commissioner of the Department of Health, torein in the costs of cardiac surgery. This approach relies onstrategies that selectively reduce the use of inappropriate orunnecessary health services, while preserving access to necessaryand effective care.

He believes that we have the tools to measure the effectivenessof procedures, and thus identify unnecessary care, but have notyet made the investment needed to develop specific applications."If we don't make that investment today, then 5 years fromnow, or whenever the cost control issue ascends to number one,we'll be saying the same thing that we do today: It will taketoo much time."

Dr. Chassin urged the society to use this window of opportunityto "set the agenda" and take a leadership role in theeffort to measure quality. He believes that specialties that takeit upon themselves to improve quality and demonstrate accountabilitywill be better situated in the next round of federal actions.

The New York State example in the area of cardiac surgery is transferableto hematology, Dr. Chassin believes. This program works throughstate regulations, data collection, and periodic publication ofthe data.

The state has managed through regulations to regionalize cardiacsurgery services. As a result, Dr. Chassin said, although Californiahas 60% more people than New York, it has 300% more hospitalsdoing cardiac surgery (about 120 versus 31 in New York State).Consequently, there is only one low-volume institution in NewYork (one that does fewer than 200 cases a year), while two thirdsof California hospitals are in that category.

The program has helped reduce mortality, particularly from bypasssurgery, in part through data collection, now in its 7th year,he said. Risk factors on every patient undergoing heart surgery(and, more recently, angioplasty) are taken from the medical recordto determine risk-adjusted surgical mortality data by hospitaland by surgeon.

The state then publishes those data, which results in peer pressureon hospitals and surgeons to pay attention to the problem. Interestingly,Dr. Chassin claimed, access to such data has not resulted in aflight of patients from one surgeon or hospital to another.

He noted that while the number of cardiac surgeries performedin the state increased from 12,000 to 16,000 over the first 4years of the publication program, the risk-adjusted operativemortality statewide fell by 41% (from 4.3% to 2.5%). And the numberof hospitals with statistically elevated mortality fell from fivein 1989, to three in 1990 and 1991, to one in 1992. Although thequality measurement plan is not the only reason for the improvement,the data suggest that it has had a major impact, he said.

Eliminate Overuse

In response to a question from the audience about whether costcontrol is possible without explicitly limiting services, Dr.Chassin answered that it can be done by curtailing overuse. Hebelieves that the literature supports the view that about 20%of physician activities (eg, procedures, tests) could be safelyeliminated without an adverse effect on quality.

"Quality as measured in outcomes would actually improve becausepatients would be spared the risk that goes along with unnecessaryservices," he said.