Value in Health Care:
Key Information for Policymakers to Assess Efforts to Improve Quality While Reducing Costs
GAO-11-445, Jul 26, 2011
The U.S. has devoted an increasing proportion of its economy and federal budget to the provision of health care services, but high levels of spending do not guarantee good care. Policymakers, health practitioners, and others have implemented numerous health care interventions that make discrete changes in the organization of health care services in order to enhance the value of health care--that is, improve the quality of care while reducing costs. Examples include programs to reduce bloodstream infections and to coordinate patient care following hospital discharges. This report (1) examines the availability of evidence on the effect of selected interventions on quality of care and costs; (2) identifies key dimensions for assessing the strength of such evidence; and (3) examines factors that can facilitate the implementation and replication of health care interventions. GAO identified a broad and diverse set of health care interventions using published and unpublished sources. For 127 of those interventions, GAO analyzed responses to a questionnaire that it sent to persons knowledgeable about available information on the effect of that particular intervention on quality of care and costs. GAO's questionnaire also asked respondents to assess the relative importance of seven factors in the implementation and potential replication of the health care intervention. In addition, GAO consulted the methodological literature and experts on assessing evidence on the effects of health care interventions.
About half of the respondents to our questionnaire reported some information on the effect of an intervention on both quality of care and costs--the two types of data needed to determine whether or to what extent a particular intervention enhanced the value of health care. Overall, the vast majority of our respondents reported at least some information on the observed effect of the intervention on quality of care. Relatively fewer--though still over half--of our respondents reported at least some information on the effect of the intervention on costs. Whether or not policymakers can rely on information that indicates an intervention enhances value depends on the strength of the underlying evidence about quality and cost effects. From studies on the effect of health care interventions on quality of care and costs, policymakers and others can assess the strength and limitations of available evidence along three dimensions. One, the credibility of evidence on the effect of health care interventions on quality of care and costs depends primarily on whether those studies apply rigorous study designs. Two, the applicability of the results of studies to a broader population depends on the extent to which the study population is representative of that larger population. Finally, the capacity of health care interventions for widespread replication can be examined in terms of the consistency of results obtained by each intervention across diverse health care organizational contexts. Respondents reported, generally by large margins, that leadership support as well as other factors, such as organizational culture and staff resources, significantly facilitated implementation. However, respondents were more divided when asked about the reported effect that health IT had on implementation, and most respondents reported that financial incentives were not a factor in the implementation of the intervention. A majority of respondents reported that each of these factors, with the exception of financial incentives, would be either very or somewhat important if one were to attempt to replicate the intervention as widely as possible. Progress in achieving greater value in the U.S. health care system will depend, in part, on the availability of information regarding the effect of interventions on quality of care and costs and on how policymakers and others assess and use that information. Information can guide the choices of policymakers among multiple interventions vying for support, but those decisions will have a sounder basis if the information meets certain criteria regarding its content and strength of evidence. At least some information on both cost and quality effects was available for about half of the interventions GAO examined. However, for many interventions the credibility of this information was put into question by widespread reliance on studies that did not incorporate rigorous designs that could isolate the effect of an intervention from other factors. We requested comments from the Department of Health and Human Services, but none were provided.