Addressing Issues

Aligning Payment Policies with Quality Improvement

Background

It is estimated that 10-15 percent of preventable mortality in the United States could be avoided by better availability or quality of medical care.1 A much larger proportion of preventable mortality, about 40 percent, could be avoided by preventive interventions to modify behavior patterns.2 It is estimated that 30 percent of annual health care costs in the United States -- about $390 billion -- are a direct result of inadequate quality health care. 3

Behaviors such as smoking, sedentary lifestyle and unhealthy eating are major contributors to diabetes, heart disease and other chronic illness and have a great impact on the health of the U.S. population that is likely to shape future health policy priorities.2

Ranked the fifth most costly disease, diabetes is an important target for initiatives to reduce health care costs.3 The direct and indirect costs of diabetes are more than $98 billion annually.4 Under diagnosis and inadequate treatment of diabetes results in unnecessary expenditures as well as tens of thousands of cases of premature death, heart attacks, stroke, limb amputations, kidney disease, and blindness.

Current payment methods do not adequately encourage or support the provision of quality care. Fee-for-service payment methods for physicians and hospitals raise concerns about the potential overuse of services, while capitation and per case payment methods raise concerns about potential under use. All payment methods affect provider and patient behavior as well as the quality of care delivered yet the concept of linking payment policies with quality health care is relatively new.

Fixing quality problems within health care requires the redesign of systems and processes as well as changes in the practice of individual health care providers. Members of the health care team (such as: physicians, diabetes educators, nutritionists, pharmacists, etc) need fair compensation as well as decision-support tools to improve quality.3 5 Employers, other purchasers of health care, and health plans that are intermediaries between purchasers and providers, also play an essential role in promoting system redesign. Click here to find out more about Team Care. Click here to find our more on the role of Pharmacy, Podiatry, Optometry, and Dentistry in diabetes care.

Subtopics within this section include

• Barriers to integrated care and the need for affordable insurance coverage.
• Perspectives on fixing the problem of inadequate care:
  • Institute of Medicine (IOM) Recommendations 5
  • The purchaser role in fixing the problem
  • The provider role in fixing the problem
  • Centers for Medicare and Medicaid Services role in fixing the problem
• Incentives and rewards for improvement
• Opportunities to improve the population's health and quality of life
• Examples and a case study
• Resources

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