In This Issue

September 2005 | Bradford H. Gray

The public disclosure of comparative information about the quality of health care providers has been advocated in terms of the rights of patients as consumers and as a stimulus for quality improvement, although serious questions have been raised about the validity of the information and the effects of its disclosure. Long-term care is an important case in point because nursing homes and home health agencies that are certified by the Medicare and Medicaid programs are now subject to uniform requirements regarding data reporting and public disclosure. In the first article in this issue of the Milbank Quarterly, “Improving the Quality of Long-Term Care with Better Information,” Vincent Mor provides an overview of the background and development of the quality-reporting system for long-term care and examines evidence regarding the issues raised by the reporting requirements.

These issues include questions about the validity and reliability of the quality measures that are publicly reported, whether providers have been stimulated to improve quality, how well the interests of consumers are being served by the present system, and whether quality “benchmarks” can be adopted to identify the “best providers.” Mor concludes that systems for reporting quality-relevant data have “begun to transform” the nursing home and home health industries but that the measures currently in use do not capture a “global notion of quality.” Mor suggests that further efforts to improve the quality measures are both needed and feasible, and he argues that the need for research on quality measurement is particularly pronounced in the field of home health care.

The next article addresses the evidence pertaining to a related and deceptively simple question that has major implications for the future shape and financing of health services in the United States: whether the prevalence of disability is decreasing among older Americans. In “Perspectives on the Recent Decline in Disability at Older Ages,” Douglas Wolf, Kelly Hunt, and James Knickman discuss the conflicting recent evidence about this question, including research suggesting that the prevalence of disability is declining and research indicating that the apparent decline is a methodological artifact. Using data from the National Long-Term Care Survey, they contend that disability is not decreasing as quickly as previously reported. Declines in reported disability may be due to changes in technology, the supply of informal care, and perceptions of disability.

Measurement issues are central also to the third article in this issue. Self-ratings of health status are widely used in health services research. An underlying and often unrecognized assumption is that the relationship between self-ratings and objective measures of health status does not vary across different demographic segments of the population. But is this the case? In “When Mental Health Becomes Health: Age and the Shifting Meaning of Self-Evaluations of General Health,” Jason Schnittker explores how and why the association between objective health and self-rated health changes with age. He shows that the association between self-rated health and both functional limitations and chronic conditions weakens with age. The reason, Schnittker proposes, is that people make social comparisons when self-assessing their health, comparing themselves with others of the same age. However, the association between self-related health and depressive symptoms increases with age. In this sense, mental health becomes health as people age. Schnittker discusses the implications of these patterns for both research and policy.

The fourth article in this issue is concerned with care for the seriously mentally ill in the United States, an unresolved problem with an unhappy history of long-term stays in state facilities and, more recently, the deinstitutionalization of patients into a system of community care that was more of an ideal than a reality. In 1977 a presidential commission was appointed to provide guidance to the nation regarding how these needs should be met. In “Public Policy and Mental Illnesses: Jimmy Carter’s Presidential Commission on Mental Health,” historian Gerald Grob describes the factors that led to the creation of this commission, the political battles that ensued regarding how the topic should be defined and whose voices should be heard, the massive amount of work that culminated in the commission’s report, and the fate of the commission’s recommendations first when they reached Capitol Hill and subsequently when they were superseded by policy changes (a block grant program for federal mental health dollars) after the Reagan administration took office in 1981.

Among the many themes that Grob develops is the importance of whether the problem confronting policymakers is defined in terms of mental illness or mental health, and the complex array of political forces and arguments that are elicited when “mental health” is defined as the challenge. Grob notes that many of the policy dilemmas considered by the Carter commission remain with us, including the relative priority that should be given to people with serious and persistent mental illness compared with those with less serious problems; how responsibility for treatment costs should be allocated across various levels of government and private purchasers; whether incremental rather than systemwide change is the better strategy for reformers; how social and biological determinants of mental illness can be distinguished; and whether (and how) mental health policy should be integrated into general health policy.

The last article in this issue is “Contribution of Primary Care to Health Systems and Health” by Barbara Starfield, Leiyu Shi, and James Macinko. The availability of primary care, they maintain, should improve the health of patients and populations by giving patients easier access to needed services, offering better care, focusing more on prevention, managing health problems earlier, and reducing “unnecessary and potentially harmful specialist care.” They summarize the evidence regarding these matters from the United States and other countries in three research traditions: studies of the relationship between the availability of primary care providers and the health status of populations, research on the health status of people who receive care from primary care physicians, and research on whether the adequacy of primary care affects health. Arguing that the research evidence strongly supports the value of systems organized around primary care, they end with a discussion of the policy challenges related to improving the role of primary care in the health systems of industrialized countries.

Bradford H. Gray
Editor, Milbank Quarterly

Author(s): Bradford H. Gray

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Volume 83, Issue 3 (pages 329–331)
DOI: 10.1111/j.1468-0009.2005.00404.x
Published in 2005