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Effectiveness research complements the biomedical research that is the scientific substrate of both clinical medicine and clinical epidemiology, which emphasizes the incidence and prevalence of disease. It adds an important dimension to these efforts by helping physicians and other health professionals, patients, the public, and policymakers better understand what can be expected from alternative courses of care, a key requirement for making determinations about value.

Therefore, adequate support of effectiveness research, as well as biomedical research, is a necessary and integral part of any health care reform plan that hopes to improve the value received for our investments in health care.

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Health services research might be said to comprise a focus on the health status of individuals, populations, or both; review or analysis of health systems, health interventions, and the factors that influence health status; a comprehensive set of variables involving health care techniques, practices, programs, and policies; and the combination and integration of these variables in many ways, frequently emphasizing the nonbiological aspects of health and medical care IOM, e; see also IOM, From this listing, the relevance, if not the absolute necessity, of health services research should be clear.

The committee believes that reform proposals serious about self-evaluation will make support for such a research agenda a high priority. Others may directly or indirectly call for efforts at technology assessment, development and application of clinical practice guidelines, and various consumer education and outreach activities. Still others advocate various changes in the nation's approach to malpractice liability e. All these matters are within the health services research purview. The committee believes that among the specific areas deserving attention are quality measurement, assurance, and improvement IOM, h; f and clinical practice guidelines issues, particularly with respect to techniques of development, methods of dissemination and application, and evaluation IOM, d, b.

Therefore, for purposes of informing the full range of health care reform efforts over the ensuing decade, a sustained investment in general health services research equivalent to that for effectiveness research, if not for biomedical research, will be needed. Hand in hand with clinical evaluation and health services research, as well as biomedical research, go health technology innovation and assessment. Changes secondary to health care reform are expected to affect the use of existing technologies e. For these reasons, the committee recom mends that steps be taken to improve the nation's capacity to execute effective technology assessments and that reform proposals be explicit about how they will deal with the innovation and diffusion of health technologies.

Questions about the impact of cost containment on the innovation, development, and diffusion of medical technologies can be expected to arise, so ideally reform packages ought to anticipate these issues even if they cannot at this early stage propose definitive plans for managing technological innovation and change IOM, g, c.

Given the scarce resources available in the public sector for technology assessment, mechanisms for setting priorities for technology assessment deserve attention IOM, f. Finally, as is true for the development of practice guidelines, quality criteria, and similar informational, educational, administrative, or evaluative tools, some efforts will need to be directed at developing better methods to establish a consensus about good or poor health care practices and to carry out appropriate studies of the costs and benefits i.

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Health care reform is understandably focused on issues relating to personal health care services. The committee recognizes that many factors that affect the health of the population e. The committee strongly urges that reform proposals explicitly recognize the need for support of the public health sector. These recommendations dealt both with structural aspects of public health, including the governmental role in public health and types of responsibility at the federal, state, and local government levels, and with organizational focal points for public health, special linkages to, for instance, environmental health, mental health, and care for the indigent , strategies for capacity building, and education for public health.

A partnership between the personal health services system and the population-based activities of the public health system, as well as occupational health activities, should be encouraged in the reform proposal. This partnership is essential for dealing with many significant health issues, such as AIDS, resistant strains of tuberculosis, unhealthy dietary practices, substance abuse, case-finding and outreach, and emergency services. By explicitly recognizing these important links, the reform proposal can avoid the unintended starvation of public health programs in the competition with health care reform for scarce public funds.

The earlier discussion of access noted that the needs of special populations may require targeted public programs. It also emphasized that the role of existing public programs, in particular, Medicare for the elderly and disabled and Medicaid for some of the poor, will have to be defined. These are infrastructure as well as access issues. It is hard for the committee to conceive of successful health care reform over the long run that does not address the real and perceived problems related to our current system for dealing with medical liability for bad clinical outcomes.

Reform proposals should, at a minimum, acknowledge these problems and either define general directions for tort reform or specify a process and timetable for defining such directions and translating them into specific policy proposals. This committee, however, lacked the resources to define those directions as they relate to changes in tort law, adoption of alternative structures for dispute resolution, and similar options. The discussion below highlights points raised in IOM reports on quality of care and clinical practice guidelines. A major criticism of the current system for determining medical liability is that it is not a reliable vehicle for screening out or rejecting unwarranted claims of malpractice.

Less prominent in much of the discussion of tort reform is the criticism that the current system leaves much malpractice unidentified and unremedied IOM, g.

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Tort reform efforts should acknowledge both criticisms of the current system and should recognize the role of quality assurance programs and other vehicles for responding to elements of these criticisms. First, improved programs of quality assurance and continuous improvement can do much to detect performance problems, identify their causes, and develop administrative and clinical strategies for improving performance and avoiding future problems IOM, h, g. A preventive approach clearly has advantages over after-the-fact compensation of victims, although the latter is also appropriate.

Second, the grievance process recommended in the preceding section of this report may deflect some unwarranted claims of malpractice. It may also lead to acceptable resolution of some real cases of malpractice without the expense and trauma of a trial. Third, clinical practice guidelines have a role to play in efforts to reduce the incidence of malpractice and to resolve specific claims of medical liability IOM, g.

Some guidelines may target specific sources of malpractice suits e. In the context of changing judicial views of the appropriate standard of care, guidelines may help judges and juries better identify bad outcomes due to substandard care. Further, guidelines formulated to help patients better understand the likely benefits and risks associated with treatment alternatives may reduce litigation inspired by poor communication and disappointment resulting from unrealistic hopes.

However, another IOM study committee has concluded that it was premature to endorse state legislation granting practitioners immunity from liability if they have practiced in accord with guidelines developed at legislative behest IOM, g. The committee was concerned about weaknesses in the processes for developing such guidelines and assessing their soundness. It also believed that plaintiffs as well as defendants should be able to cite robust guidelines in their arguments. Malpractice and tort reform are complex issues that perhaps need not be woven directly into health care reform from the outset, although some committee members thought otherwise.

The options for malpractice and tort reform go far beyond the points we have discussed above. These options include statutory reforms such as barriers to suits or reductions in damage awards , arbitration and mediation as alternatives to litigation, no-fault approaches, various kinds of administrative programs that may involve disciplinary fault-based actions like those now in theory done through licensure boards , so-called early offers of settlement done on a voluntary basis by offending providers and practitioners , mechanisms based on private contracts between providers and patients, and enterprise liability in which institutions such as hospitals, health plans, or others undertake to cover individual practitioners in malpractice situations.

Little or no empirical evidence suggests which of these strategies might be effective in which situations, and hybrid arrangements might also be possible. The committee believes that reform proposals should, at a minimum, acknowledge the need for change and perhaps indicate what strategies would appear to mesh best with the type of reforms envisioned.

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Dr Roberta Bernardi

Although reform proposals vary in their emphasis on the consumer as an informed purchaser of care or the patient as an informed decisionmaker about courses of treatment, the proposals share a common infrastructure requirement: more extensive and effective public and patient education programs and tools.

Market-oriented reforms require explicit attention to the kinds of comparative information provided to individual purchasers of health plans, the source and accuracy of that information, and its real utility. The conditions for effective consumer decisionmaking may also include other changes discussed in this and other IOM reports, for example, some standardization of benefit design and regulation of health plan marketing practices.

To educate individuals faced with making decisions about possible courses of care for specific medical problems, clinical practice guidelines that consider outcomes relevant to patients and variations in patient preferences for different types of care and outcomes can—in the form of practitioner guidelines—help physicians and other health care practitioners better educate patients and—in the form of patient guidelines—help directly build patient understanding.

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New educational media such as the interactive video disc technology may at the same time standardize the information provided to patients and increase its relevance. Reform proposals should be clear about the roles, responsibilities, accountabilities, and interrelationships of the public and private sectors in implementing the proposal and achieving its objectives. Reform packages should be clear and realistic about the time-table expected for full implementation. Monitoring mechanisms will be needed to detect inadequate implementa-tion, unanticipated negative effects, and positive results that should be built upon.

Any plan should make clear how it will deal with issues of human and physical capital supply and distribution. Health care reform proposals should describe policies and priorities that determine the role of various providers, including nurses and physicians, and the settings from which they should deliver care.

Reform proposals should include a specific mandate for the development and continued support of comprehensive data-bases in the health field. Reform proposals should promote universal implementation of computer-based patient records CPRs and CPR systems among providers. The committee also recommends adoption of an expanded program in information services for health services research and technology assessment at the National Library of Medicine.

The committee recommends an absolute increase in the support for a range of research and information activities that must be carried forth if reform activities are to be implemented and evaluated satisfactorily, particularly in the area of clinical evaluation sciences and health services research. The committee recommends that certain steps be taken to improve the nation's capacity to carry out effective technology assessment efforts and that reform proposals be explicit about how they will deal with the innovation and diffusion of health technologies over time.

The distinction between efficacy and effectiveness is important. In contrast, effectiveness refers to the outcome of an intervention when applied in the daily practice of medicine to the medical problems of typical patients; research in this area is supported chiefly by the Agency for Health Care Policy and Research. Obviously, public servants should be able to count on the support of elected officials to bring about legislative changes to marshal reforms that affect the whole of government. But by and large, the public service should take responsibility for on-going reforms and bring about the necessary improvements in order to fulfill its mission.

It borrows from private sector management practices without adapting them to public sector values and principles, and. It erodes the professional public policy role by transferring it to the political level or to independent organizations.


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That being said, the frustrations and the disenchantment of citizens with the public service, which led to NPM, are only too real. Citizens demand and deserve high quality service exempt from patronage or influence peddling. They expect access to information, and they expect services to be organized and delivered in accordance with their needs and circumstances, not at the convenience of departments or civil servants.

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The second challenge, therefore, is to accept the responsibility to bring about the changes within our power. The public service model, as we know it today in most countries, was inherited from the industrial age. It is the result of the work by Adam Smith, F. Taylor, and Max Weber. The Weberian concept of the Public Service in the 19th century:. These basic principles remain valid today. However, Author strongly believes that we need to modernize their definition and their application. To illustrate this point, the author refers to the rule of law, the merit principle and the need for due process.

Our commitment to these principles should never be used as:. Unlocking the human potential of the public service starts with facing the truth, no matter how uncomfortable this may be at times. Firm commitment is to leave the future generation with better institutions than the ones we inherited. The respect for the rule of law is one of the most fundamental principles of public sector institutions.

Unfortunately, incidents related to the inability to eradicate corruption and take forceful action to address proven incidents of wrongdoing continue to undermine the credibility of the public service and public servants. This is not a matter of a Minister alone. Much can be done in the public service by public servants at all levels. It is necessary to protect the public service from political interference in the recruitment and promotion processes, in order to build professional and highly competent institutions.

The commitment to due process is no justification for red tape, or inefficient and disjointed operations in Government. The public sector is not inherently less efficient than the private sector; more complex, yes, but not less efficient. Many of the policies, controls and procedures are not required to fulfill the requirements of the rule of law. They serve instead to satisfy the appetite for control and power by some, at the expense of the commitment to serving citizens.


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