Department of Health and Human Services Secretary Mike Leavitt recently highlighted for the nation that: “America’s health care sector is shifting rapidly to a system where patients can get better information about the quality and cost of their care, and there is competition to provide them with the best value.” Within a year of launching the Department’s Value-Driven Health Care Initiative, more than 100 million Americans are being served by health plans that are committed to providing consumers with transparent quality and cost information. “We are organizing the health care market to achieve better quality health care, at lower cost, for all Americans. That is the definition of value. Yet until now, our health care system has been marked by a lack of consumer information to support value-based decisions.” In August, 2006, President Bush signed an Executive Order committing the federal government to the “four cornerstones” of value-driven care: Health information technology; Public reporting of provider quality information; Public reporting of cost information; and, Incentives for value comparison.

The Institute of Medicine (IOM) projects that the changing environment of health care – i.e., the increased public reporting of performance measures and new conceptual payment incentives for providers who meet certain quality standards – will create a growing demand from providers for technical assistance with the reporting of performance measures and analysis, as well as with process and systems improvement.

Presently, Americans too often do not receive quality care that meets scientifically established guidelines and as a result suffer worse health outcomes. Adults, on average, receive just more than half of the clinical services known to be beneficial for their conditions and often receive many unnecessary services. Wide disparities exist in the use of services and patterns of health care based upon geographic location, the supply of health care services, and race and ethnicity. Ethnic disparities in the treatment of Medicare beneficiaries are becoming increasingly evident, with minorities receiving lower-quality mental health and preventive care services, on average, than whites and Asians. Per capita spending on health care in the United States is higher than that in any other developed country and yet, comparable health outcome measures consistently leave much to be desired.

The IOM has proposed six aims for quality health care – Safety, Effectiveness, Patient Centeredness, Timeliness, Efficiency, and Equity – as well as the vision of driving fundamental change in the environmental factors affecting health care delivery to enhance quality and performance. Health information and communications technologies, which could contribute significantly to improved quality, are available, but their adoption by providers has been slow. For example, among physician practices generally, only 18 percent of physicians use electronic health records; for those in solo or small group practices, the figure is just 13 percent.

Soon after the enactment of Medicare in 1965, concerns were raised about the quality and cost of services being provided. Fortuitously, P.L. 89-97 had also focused upon patient safety and access to care from competent health care providers. Hospital-based utilization review, practitioner licensure, and hospital accreditation were the initial quality assurance mechanisms. Experimental Medical Care Review Organizations (EMCROs), Professional Standards Review Organizations (PSROs), and Utilization and Quality Control Peer Review Organizations (PROs) were subsequently authorized, each with a distinct emphasis upon physician involvement and local peer review.

Over time, there has been a gradual shift from focusing solely upon punishing individual outliers to instead systematically improving the overall delivery of care by collaborating with providers. Today, a fundamental question is whether Medicare’s Quality Improvement Organization (QIO) efforts, which exist in every state (augmented by research projects funded by the Centers for Medicare and Medicaid Services (CMS)), will ultimately become capable of assuring quality care? The IOM: “(T)here still is a huge gap between what is known about quality care and the care that is delivered to most patients.... (M)any health care providers and practitioners need help in making the changes necessary for the consistent delivery of high-quality care.” The governing boards of QIOs, in general, lack a broad representation by individuals with different areas of expertise and are especially deficient in their consumer representation. Issues surrounding physician autonomy make behavioral changes particularly complicated and since health policy experts consider physicians “experts” because of their highly specialized knowledge, they generally believe that it is difficult for nonphysicians to evaluate their work and be heeded. Nevertheless, the IOM has called for a broader representation of various disciplines and expertise to make QIO efforts more relevant and effective.

Although the federal government has been involved in exploring quality assurance for Medicare beneficiaries for over 35 years—gradually evolving from a focus upon retrospective utilization of individual case records to a posture of systemic collaboration with providers on overall patterns and processes of care—we would suggest that very few psychologists have been involved in this effort or, in all candor, are more than superficially knowledgeable about its long term implications for psychological practice. Medicare is the single largest purchaser of health care in our nation; in 2004 the program paid more than $295 billion in benefits for 41.7 million beneficiaries. As we have matured as a healthcare profession, our leaders have collectively come to appreciate that changes in Medicare eventually effect all public and private health care initiatives, including insurance reimbursement rates and conditions of participation. CMS urges that quality assurance measures which are ultimately utilized be scientifically and clinically sound; be reproducible; not add burden to the provider; and, use existing data sources. As we enter the 21st century, there are definite signs that our nation’s elected officials will increase their call for a coherent national system which supports (and ultimately requires) robust performance measurement and public reporting. The unprecedented advances occurring within the communications and technologies fields will make data-based clinical decision making and provider comparisons to “gold standards of care” that which society will expect when demanding “quality care.”

When involved in the public policy process, it can be fascinating to reflect periodically upon the changing waters that are seemingly passing by. The National Institutes of Health (NIH) is truly an investment in our nation’s future – in our citizenry’s health and well being. This year’s budget requests $28.9 billion. NIH research priorities are extraordinarily important to our nation’s scientists and academics. APA and APS staff work hard to insure that the behavioral sciences are given appropriate recognition. Yet in all candor, our practitioners and public interest colleagues traditionally have been less involved, if at all interested. Recently, however, there has been a qualitative shift in NIH’s focus; perhaps as a result of the Director’s vision for the NIH Roadmap. During this Spring’s U.S. Senate Appropriations Committee hearings, rather than focusing exclusively upon advances in reducing, for example, the mortality rates of cancer (the second-leading cause of death in the United States), the witnesses also discussed the challenge of bringing practitioners into the 21st century – of assisting practitioners in developing and following clinical guidelines; i.e., “gold standards” of care. The critical nature of the reimbursement system was also raised by both scientists and Senators. It would be nice to hear more about the importance of psychology, the psychosocial-economic-cultural gradient of care, and the contributions of our nation’s non-physician health care providers. Nevertheless, the vision and enthusiasm of the witness was truly inspiring, if not infectious.

The NIH Director: “The 21st century will be for the life sciences what the 20th century has been for the physical sciences. Mastery of the biological world will impact not just health, but also our ability to develop sensitive solutions to environmental and energy challenges and will be a key determinant of national competitiveness. One of the greatest challenges facing our society is the unsustainable growth rate of healthcare expenditures. NIH and its scientists deeply believe that we are in a transformative phase of the biomedical and behavioral sciences, where opportunities for discoveries and their translation have expanded considerably. We believe that we are on a path to transform medicine from the current practice of intervening often too late in a disease process, to a new era when medicine will be more predictive, personalized and preemptive, through a broader scientific understanding of the fundamental mechanisms that lead to disease years before it strikes the patient.... (This) is no longer just a dream but a vision to strive for, because it can reduce disease burden and its costs while improving individual quality of life.... The treatment of cognitive decline and mental disorders continues to improve at an incredibly rapid pace. In 2006, NIH supported the development of new strategies that helped depressed patients become symptom-free and prevented disease recurrence in older adults with single-episode depression....

“From Curative to Preemptive Medicine. Historically, medicine has been reactive, and patients did not seek attention until an acute event required them to seek a doctor’s cure. Our system of care is based on managing these late events on an episodic basis – an increasingly costly and unsustainable approach. What then is the scientific vision for change? Our goal at NIH is to usher in an era where medicine will be predictive, personalized and preemptive. This trend will also require a transformation in the fundamental relationship between healthcare providers and patients, necessitating continuous participation of individuals, communities and healthcare institutions as early as possible in the natural cycle of a disease process. Based on NIH-supported research, we now know that many of the most prevalent diseases of our time begin silently, many years before they inflict their obvious damage to patients. Increasingly, we are able to identify biomarkers that are predictive of the likelihood of developing a serious condition later in life.... (M)ore predictive and personalized treatments could improve the safety and effectiveness of drugs. We know that drugs do not fall into the ‘one size fits all’ category. The same drug can help one patient and harm another. Recent research shows that we will be increasingly able to know which patients will benefit from treatment and which patients might be harmed. This field of study is known as pharmacogenetics....

“Building toward the future involves innovations in multiple areas, including technology, research and training paradigms, information interoperability, and greater knowledge and resource management. We have seen an explosion of new discoveries and novel opportunities for progress across all areas of science – from the most basic discoveries to the sequencing of the human genome, to the development of fields that simply did not exist a few years ago.... The opportunities for significant advances exist on virtually every front.... We are also working to preempt disease through evidence-based education that draws on the best behavioral and social science research....”

Witnesses from the Institutes supported the Director’s vision, describing exciting collaborative projects. The National Library of Medicine (NLM): “The NLM has a remarkable track record of preserving the past while serving the present and preparing for the future. A just completed Long Range Plan... lays out in broad terms the challenges the Library will face over the next decade and charts a course for action to successfully meet these challenges. Prominent among the challenges is the need to create the information resources essential to achieving the goal of ‘personalized medicine,’ in which prevention and treatment strategies are tailored to an individual’s specific genetic make-up. The first step is to provide huge linked databases and software tools that allow scientists to correlate clinical, genomic, and chemical compound data with published research findings to determine how genetics and a person’s environment interact to cause disease and to identify potential new therapies. Such resources, now being developed by NLM, will speed scientific discovery and can ultimately transform medical care by allowing clinicians to customize treatments to a patient’s genetic characteristics.

“In an era of increasing chronic disease, a related challenge is the need to empower people with the knowledge and motivation to improve their health and play a more active role in their health care. The information that pours out of the nation’s laboratories – and often finds its way into the public media – has the potential of improving the health status of our citizens. The NLM has created heavily used Web-based information services aimed at the public.... Electronic health records with advanced decision support capabilities will be essential to achieving personalized medicine and will also help people manage their own health. Much of the seminal research work in this arena was supported by the NLM.... This work builds on two decades of research and development... which help computer systems behave as if they ‘understand’ the language of biomedicine....

“The audiences served by the Library have multiplied in recent years. In addition to providing researchers and health care providers with access to scientific information, the NLM also now has services for the public – from elementary school children to senior citizens. The Library’s main portal for consumer health information is MedlinePlus.... In addition to more than 700 “health topics” (main entries on diseases and disabilities), MedlinePlus has interactive tutorials that are useful for persons with low literacy, medical dictionaries, a medical encyclopedia, directories of hospitals and providers, surgical videos that show actual operations, and links to the scientific literature.... A number of NLM’s advanced information services and tools are designed for use by emergency responders when disaster strikes....”

How will psychology respond to the challenges of the nation’s healthcare environment? Are practitioners listening to the Practice Directorate? Will we be involved in the public policy process at the state and national level, thereby controlling our professional destiny? Secretary Leavitt has called for “the leadership of physicians and other health professionals to achieve reliable information about health care quality and costs. Medical associations and others have begun the work of developing quality standards and cost measurement, but we have many years of work ahead of us to achieve the wide-ranging and meaningful quality standards we need.” The visionary efforts of former APA President Ron Levant and Treasurer Carol Goodheart to address the complexities surrounding Evidence Based Practice for psychological care are truly serving our practitioners admirably.

Aloha.

Pat DeLeon is a former APA President.