To the Editor.—While we applaud the efforts
of Drs Lundberg and Wennberg1 with their
challenge to the medical profession, a challenge that has been notably long
absent, their call already has been answered, at least in part, and, ironically,
reported in JAMA.2
Structurally, the suggested framework of their proposal for a program
addressing quality improvement currently exists in the Health Care Financing
Administration Peer Review Organization (PRO) program that has been in place
since 1984. This quality improvement infrastructure, required by the Social
Security Act for the Medicare program, is in place for every state and US
territory. Despite past references to governmental slowness, the Health Care
Financing Administration remains at the forefront of quality improvement with
its PRO Health Care Quality Improvement Initiative. Specifically, PROs, in
conjunction with local and national collaborators, already identify high prevalence
and high impact medical conditions as targets for quality improvement and
use all the methods that Lundberg and Wennberg propose as a means to obtain
measurable improvement. Well-documented improvements have occurred and more
are sure to come.3- 4 Of
the suggested topics for intervention, the National Cooperative Cardiovascular
Project is just one example where measurable improvements in the PRO community
have already occurred on a local, regional, and national level for use of β-blockers
and for several other indicators. The PRO program could be expanded to provide
the infrastructure for all patients, and there are compelling reasons to expand
the scope of this program. The federal government remains the largest purchaser
of health care in the United States, and while the private sector has demonstrated
the capacity to adapt to a changing market, there is concern that cost rather
than quality is the driving factor.