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Results in Brief
GAO found reasons for concern about current systems for monitoring Medicare quality of care. Review methods of uncertain validity are being used, quality of care problems identified by one set of reviewers are not coordinated for action by others, and the accuracy of key information is questionable. Further, Hys's strategy for developing quality assurance methods is inadequate to meet future program needs. GAO identified short-term efforts that could lead to significant improvements in the problems identified. However, Gao also found that developing a comprehensive quality assurance research base and creating a program for incorporating this knowledge into Medicare quality assurance efforts would require a long-term commitment that cannot be adequately supported by current resources.
The Effectiveness of
The effectiveness of the medical review activities of carriers, intermediaries, and PROS in identifying quality problems or positively changing physician or provider behavior has not been evaluated. The oversight of medical review activities focuses on whether they meet contract specifications, most of which relate to controlling utilization, rather than on whether these activities effectively identify quality problems or lead to improvements in medical care.
The medical review activities of carriers, intermediaries, and PROS with respect to quality of care are virtually independent. Each set of reviewers applies both its own and HCFA-developed computer and manual edits and screens to billing and medical record data. They independently build profiles of provider or practitioner performance to identify possibly problematic patterns of service delivery or patient outcomes. Profiling results are not routinely shared among PROS, carriers, or intermediaries reviewing care in the same geographic areas. Possible quality of care problems found by carriers and intermediaries are not systematically reported to either HCFA OG PROS. If a patient qualifies for Medicare posthospital services and the intermediary suspects that the hospital discharge may have been premature, HCFA is notified. But if posthospital coverage is denied by Medicare, there is no mechanism, other than beneficiary complaints, for notifying either HCFA or PROS about possibly inappropriate or premature discharges. HCFA's planned reorganization of Medicare data systems provides an opportunity to substantially improve coordination of quality monitoring activities.
ity of Care Data Are of Questionable Accuracy and Not Generalizable
The data that support medical review as well as the information gener-
HHS's Strategy for
HHS is supporting many useful studies addressing aspects of quality of
Recommendations to the Secretary of HHS
To strengthen the process of medical review, Gao recommends evaluations of (1) the comparative effectiveness of carrier and intermediary screens and profiles as means to identify inappropriate and substandard care (p. 39), (2) the methods PROS use to review medical records and the utility of current methods for establishing their quality of care contract objectives (p. 64), and (3) the methods PROS use to review quality of care in Medicare prepaid health plans (p. 64). To improve coordination of medical review activities, GAO recommends (4) that formal guidelines be developed to coordinate the systematic and timely reporting by carriers and intermediaries to PROS and HCFA of possible quality of care problems (p. 41), and (5) that studies be initiated to assess the strengths and weaknesses of the division of responsibilities among carriers, intermediaries, and PROS for processing and screening Medicare claims data
and performing medical reviews to identify quality of care problems and
The Subcommittee on Health should consider developing legislative proposals to assign specific research and development responsibilities to a new federal entity or existing entities for (1) developing, disseminating, and coordinating activities intended to define good medical practice and develop improved quality assurance methods, and (2) incorporating this knowledge into Medicare quality assurance efforts. Possible locations for these activities are discussed in chapter 7 (p. 110).
HHS agrees in principle with all or part of most of GAO's recommenda-
Assessing Quality of