Closing the gap in quality health care for Americans.

My subject tonight is the dichotomy between the success of individual physicians and what I believe to be the failure of our profession to assume a true leadership role in furthering the health of Americans. I believe that there is a narrow window remaining during which professional leadership is possible, but I believe even that window is beginning to close. Health care is about access, quality, and cost. Unfortunately, organized medicine lost the opportunity to provide real leadership in areas of cost and access. The profession has been reactive, if not reactionary, as well as defensive, complaining, and often whining, instead of showing leadership in the public interest. As the cost of health care escalated for .3 decades, we, as a profession, had an opportunity to seriously control the rate of rise of costs in health care. Instead, we added one technology after another, often without replacing the previous technology. I am still professionally embarrassed by an experience I had several years ago in which I argued at a program of Continuing Medical Education that 90% to 95% of patients with mitral valve prolapse could be evaluated with a careful history, a thorough physical examination, and an ECG. I was attacked by several members of the audience not on the basis of scientific merit, but because I was “taking away [their] bread and butter” by not recommending an echocardiogram, treadmill test, and Holter monitor for each suspected patient; these patients constituted perhaps as many as 6% to 8% of the total practice of those present. Our assertion of the primacy of the patient-doctor relationship without serious attention to the cost-effectiveness or marginal value of what we did contributed to a healthcare system that now consumes one-seventh of the gross domestic product and in which cost is beginning to accelerate again. As a consequence of our professional failure to control healthcare costs, forces outside the profession undertook to do so. Corporate purchasers, insurance companies, managed care companies, and the Balanced Budget Agreement were among the powerful forces acting to control the rate of rise of healthcare costs. Efforts to control costs were made that were often neither in the best interest of the profession nor of the patients. We have not done any better with access. The number of uninsured Americans continues to rise every year; .44 million were uninsured last year.1 Even with incontrovertible evidence that those who are uninsured receive less than optimal health care, organized medicine has, until very recently, done little to stem the rising tide of the uninsured and of the additional millions of underinsured individuals. It is ironic that our profession bitterly fought the enactment of Medicare and Medicaid legislation when these efforts dramatically increased the number of insured Americans and ultimately produced a financial bonanza for physicians. With the notable recent exception of the leadership by the American College of Physicians, a sincere, concerted effort to extend insurance coverage to all Americans has been lacking. As a result, many other organizations are now taking the lead in extending coverage to the uninsured. The recent alliance of Families USA and the Health Insurance Association of America is an example of the kind of serious effort to reduce the number of uninsured that is being led by organizations outside of the profession. These efforts will help patients to varying degrees, but we, as professionals, are not effectively participating. I would like to see our profession, and particularly the American College of Cardiology, assume substantial leadership in areas of cost and access to care. However, I believe the last remaining major opportunity for credible, compelling, aggressive leadership is in the area of quality of health care. I will argue that the internalization of continuous quality improvement into cardiological practice and into the policies of the College of Cardiology and its members in a manner that is serious and publicly responsible can provide a method for reestablishing professional leadership in health care and, in so doing, ultimately improve access and control healthcare costs. The Institute of Medicine defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of successful health outcomes and are consistent with current professional knowledge.”2 Quality of care can be measured.3 This requires data. It has been repeatedly demonstrated that physicians who claim to know quality when they see it are often inaccurate. These data have produced incontrovertible evidence that a substantial gap exists in this country between the quality of average care and the quality of best care and that important opportunities exist for introducing continuous quality improvement into the healthcare system to close that gap. Quality of care can be measured both by processes and by outcomes. The role of b-blockers and aspirin in the management of acute myocardial infarction or the use of warfarin in the atrial fibrillation occurring in those aged 65 to 80 years are well-documented examples of “current professional knowledge” that define good processes of care, yet the