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By Marilyn Werber Serafini, National Journal
© National Journal Group Inc.
Friday, Oct. 26, 2007

Quality wasn't a big topic when presidential candidates debated health care in 2004. Today, most health care experts agree that improving the quality of care is essential to lowering costs and is an important goal in its own right.

The 2008 presidential candidates, especially the Democrats, are going into great detail about investing in technology and transforming the health care system to make price and performance information readily available for comparison shopping by patients, insurers, doctors, and hospitals. Overall, Democrats scored highest when National Journal's judges assessed the candidates' plans on how well they would enable consumers to make informed choices about medical care, and ensure that medical providers have the tools to improve care. Some judges said that the GOP plans simply aren't detailed enough yet to be scored accurately. Republican John McCain received praise for his innovative approaches to improving the health care delivery system.

One main difference between Democratic and Republican plans is that the Democrats propose spending federal money (Hillary Rodham Clinton and Barack Obama give estimates) to help doctors, hospitals, and other medical providers adopt electronic health care systems, including electronic medical records. Rudy Giuliani and McCain say they would push for standards, and Mitt Romney vaguely indicates that he wants to enhance the use of information technology.

Meanwhile, most plans count on a new health care buzzword, "transparency," to help consumers make better choices. Democrats are quite specific. Clinton would invest in a Web-based tool to help patients compare medical providers and to educate them about treatment options. Obama would require all medical providers to collect and report data on costs, quality, preventable medical errors, nurse-patient ratios, hospital-acquired infections, and disparities in care. John Edwards would create a consumer report that would compare the quality of hospitals. One judge scored Edwards's plan lower than Clinton's and Obama's in this area because Edwards's emphasis is on hospital information, not doctor information. "Most individuals don't choose a hospital. They need doctor data, too, to get people engaged," said Paul Fronstin, senior research associate at the Employee Benefit Research Institute.

McCain rated better than either of his fellow Republicans. He would require medical providers to make information available on outcomes, quality of care, cost, and price. "McCain wins on the Republican side since his emphasis is on transparency," said Len Nichols, director of the health policy program at the New America Foundation.

"Giuliani has no mention of providing quality information to consumers. Price and provider qualifications aren't enough," Fronstin said. Romney, meanwhile, "mentions cost and quality transparency, but doesn't say anything more specific," he added.

Clinton, McCain, and Obama would require government health care programs to pay doctors and hospitals more for better care, which none of their plans defined. And the three Democrats all have proposals aimed at keeping doctors in the know about best practices. Clinton specifically would pay medical providers more for coordinated care, and she would create financial incentives for doctors to participate in programs to keep themselves current. Obama would step up efforts to develop and disseminate best-practice information, and he would establish an entity to compare the effectiveness of therapies and procedures.

Edwards would change the payment systems for government health care programs to emphasize primary care and good care, and he would have the government research the best methods of providing care. McCain proposes higher government payments to providers when their medical outcomes are better, when they coordinate care, and when they provide preventive services. Giuliani would tie state Medicaid payments to success in promoting preventive care and tracking childhood obesity.

Robert Blendon, director of Harvard University's program on public opinion and health and social policy, says that McCain stands out among the Republicans because of his focus on the health care delivery system. "That's where he differs from other Republicans. He [proposed] things that people think are sensible," Blendon said. "He encouraged front-end clinics," such as the "minute clinics" that are popping up in drugstores to treat minor ailments. "Why not have doctors be able to move between states, and nurses be able to prescribe, to make things cheaper and easier? I'm not arguing that having clinics in Wal-Mart is increasing quality, [but] none of the other Republicans have anything about health care delivery," he said. "The others are so fixated on the tax system. You have to decide whether the tax system is the principal agent of change here."

The overarching question, said John Goodman, president of the conservative National Center for Policy Analysis, is which candidates' plans would spur competition. "Quality will improve if providers compete for patients based on price and quality. Competition is far more effective than imposing standards from the top down."

Quality Improvements

Hillary Rodham Clinton would pay medical providers more for coordinated care, and would create financial incentives for doctors to participate in programs to keep them current. Participating doctors, hospitals, and nursing homes would be eligible for higher payments from a $125 million pool of federal money. The Health and Human Services Department could also use that money to develop and test gauges of quality. Clinton would establish training and mentoring programs to ease the nurse shortage, and she would invest $300 million to help nursing schools expand and place graduates, improve retention of new nurses, and increase support staff. She would invest $50 million in a Web-based tool to help patients compare medical providers, $25 million to educate people about treatment options, and $3 billion a year (for a few years) to help hospitals and doctors shift to electronic record-keeping. She would provide incentives for patients in federal health programs to participate in chronic-care management programs. Clinton would create a "best practices institute," with joint federal-private funding, to compare treatments' effectiveness. John Edwards wants to change reimbursement rules, starting with federal health programs, to emphasize primary care and better care. He would establish federal standards to make sure that all insurers offer preventive and chronic-care coverage with "little or no" cost-sharing. He would establish a nonprofit or public organization to research the best methods of providing care, using data from Medicare and his proposed Health Care Markets. He would create a consumer reports program to compare hospital quality. He would support research into health disparities and require medical providers to keep records electronically. Edwards would provide federal resources to help hospitals move to automated medication dispensing, computerized physician order entry, computerized patient reminder systems, and handheld communication devices for hospital staff. He would establish requirements for nurse-to-patient ratios for hospitals, restrict mandatory overtime for nurses, offer incentives for hospitals to improve working conditions, and make it easier for nurses to collectively bargain. He would subsidize the education of nurses who commit to working in rural or urban public hospitals, and would subsidize nursing schools so that they can train more nurses. Rudy Giuliani wants to spur competition among medical providers by improving the visibility of price, provider qualifications, and outcome information. He supports public/private partnerships to set standards for health information technology. State Medicaid payments would be tied to success in promoting preventive care and tracking obesity in children. Giuliani wants to expand the practice of paying Medicare doctors and hospitals more for better-quality care. He wants to improve the process for getting medical innovations to the bedside and to reduce red tape for approval of medical devices. John McCain wants to create national standards for electronic health systems and data collection. Government health care programs would reimburse medical providers more for good outcomes, for coordinating care, and for preventive services. He would require medical providers to make information about outcomes, quality of care, costs, and prices readily available. He supports innovative health care delivery systems, such as clinics in stores. Barack Obama would require hospitals and medical providers to collect and report data on costs, quality, preventable errors, nurse ratios, hospital-acquired infections, and disparities in care. Health plans would have to disclose the percentage of premiums that pay for patient care. All federal health care plans would have to use disease-management programs. Obama would encourage team care through home-type models. He wants to step up efforts to develop and disseminate best practices information and to pay medical providers more for top-quality care. Obama wants to establish an independent institute to research comparative effectiveness, to help medical providers make informed decisions. He would invest $10 billion a year for five years in moving toward standards-based electronic health care systems. Mitt Romney wants to enhance the use of information technology, including electronic medical records, and to make information about costs and quality of care readily available.