Still crossing the quality chasm: a look at the IOM’s seminal report 20 years later

Twenty years ago, the Institute of Medicine published its seminal report, Crossing the Quality Chasm: A New Health System for the 21st Century. The IOM’s follow-up to its 1999 report To Err is Human, which examined patient safety in the U.S., Crossing the Quality Chasm was a clarion call to healthcare stakeholders and the nation, “to improve the American healthcare delivery system, as a whole, in all its quality dimensions, for all Americans.”

The March 2001 report marked an inflection point in American healthcare. The charge: Make fundamental changes to improve healthcare quality across six arenas: patient safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. Almost overnight, quality was woven into the mission and strategy of every major actor in the sector. Improving quality, addressing affordability and driving innovation became the three legs of our industry’s proverbial stool.

As we mark this milestone anniversary, we must ask ourselves: How much progress have we made in revolutionizing care delivery?

The short answer: We have made some important gains in this Herculean effort, but there is still quite a lot of work to be done. The last 20 years have brought about significant evolutions in care delivery. Deaths amenable to healthcare have steadily declined in the U.S., including an estimated 24% drop from 2000 to 2017 alone. Transparency rules have been implemented across the sector, empowering greater consumer advocacy and awareness. Investments in telehealth created the infrastructure to support a nearly 3,000% increase in virtual care utilization in 2020, a critical technology during a crushing pandemic. Patient experience is now a conventional metric used in value-based reimbursement. In all, the advancements have led to dramatic improvements in some of our most deadly and costly disease states.

However, we have fallen short on efficiency and equity, as the U.S. continues to lead the world in spending while lagging in quality outcomes. And that is because stakeholders tried to revolutionize the infrastructure of delivery without the requisite changes needed to support it. Leaving the foundational cornerstones of our country’s healthcare economy unchanged will never allow for the transformation outlined in the report.

To truly “cross the chasm”, we need to implement a level of change analogous with tectonic plates shifting. Fundamental reform will occur when:

  • Healthcare becomes a truly shoppable experience, enabling elements of a free market.
  • All perverse provider reimbursement incentives are removed or regulated.
  • Reforms focus on better outcomes rather than simply cost control.
  • We maintain focus on nonclinical interventions that drive the healthcare status of individuals.

To make the necessary strides to build a health system better equipped for the 21st century, we need to reset our expectations and approach. It is imperative to set realistic goals, tied to an achievable plan for change to ensure we’re not in largely the same place in 2041.

Efforts we undertake in the next five to 10 years will have a significant impact in sustaining improvements in care delivery. These goals include:

  • Breaking away from the sunk cost fallacy that we must only improve the industry through iterative improvements to the current infrastructure versus starting anew.
  • Accelerate transition from fee-for-service reimbursement to value-based payments by markedly increasing the percentage of revenue tied to outcomes.
  • Focus and incentivize nonclinical interventions rooted in the social determinants of health.
  • Allow people to choose their preferred modality of care and engage accordingly.

An approach that combines many of the above attributes is the integrated delivery and financing system, which evolves delivery and the economics simultaneously, in addition to fostering better coordination and cooperation among providers and payers. In fruition, it enables a patient-centered ecosystem, driving better outcomes, higher quality, and system efficiencies through aligned incentives. These systems can take the form of joint ventures, like Sutter Health | Aetna, creating an environment ripe for systemic improvement, where the entire model is optimized for progress and continued innovation.

In order to cross the chasm, we must embrace an approach that transforms not only care delivery, but the entire healthcare system and economy. In doing so, we will be able to address quality and affordability through a more plausible approach to market evolution.


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