Developing a Medicare Quality Assurance Strategy Table 7.1: Advantages and Disadvantages of Placing Comprehensive Quality Assurance Program in Existing Organizations Organization HCFA NCHSR&HCTA NIH ASPE Advantages Programmatic needs apparent, should increase relevance of quality assurance research Familianty with and access to data Strong tradition of sound peer review of research proposals Historic involvement in quality assurance research and development from diverse perspectives Experience in advising HCFA on coverage issues and cooperative research efforts Good access to health services, clinical research and medical professional communities Strong tradition of research support and sound peer review of proposals Visibility, stability, and relative autonomy Ready access to clinical researchers and medical professional community Organizational location should facilitate access to relevant agencies in HHS Responsible for coordinating planning and evaluation activities Disadvantages Weak tradition of sound peer review of research proposals Funding decisions driven by policy priorities, sometimes in conflict with technical merit of proposed research Potential conflict between quality of care needs and cost control and coverage decisions Strained relations with professional communities Indirect access to HCFA data Indirect links to HCFA program issues Unstable budget history; instability of research funding Historic disinterest in health services research Potential conflict between incentives to develop new technologies and the need to determine their effectiveness and establish practice standards Indirect access to HCFA data Indirect links to HCFA program issues Weak tradition of peer review of research proposals Limited influence over other research funding agencies with their own staff and budget Limited experience with health services research Indirect access to HCFA data Indirect links to HCFA program issues Authority to fund research limited to specific topics or immediate research needs (continued) Placing a quality assurance research and evaluation program outside Conclusion Current systems for reviewing Medicare services, assessing the extent or distribution of quality of care problems, and developing methods for measuring and monitoring quality of care are not designed to meet current or future policy and program evaluation needs. To ensure that individual covered services are provided appropriately and meet professional standards, the first priorities should be to improve current HCFA data systems, to document the effectiveness of current review Developing a Medicare Quality methods, and to determine how program data can be used to provide better information on quality of care. To identify broader problems in the Medicare population that may be associated with poor health care outcomes or the unnecessary or inappropriate use (or nonuse) of Medicare services, and to develop improved quality assurance methods that reflect changing clinical and reimbursement practices, a more comprehensive research and development program is required. This involves drawing on resources outside HCFA, including the clinical expertise, research, and methodology skills found in the Public Health Service and in the wider medical and health services research communities. It also requires the development of an organizational structure to facilitate the incorporation of emerging information on good clinical practice into the development of quality assurance methods, and ultimately, the integration of that knowledge into Medicare review activities. Matter for The Subcommittee should consider developing legislative proposals to assign specific responsibilities to a new federal entity or existing entities designed to (1) develop, disseminate, and coordinate activities intended to advance the development of quality assurance methods and good medical practice, and (2) incorporate this knowledge into Medicare quality assurance efforts. In their comments on the draft report, HHS did not concur with the concept of creating a new federal entity, stating it could result in a duplication of effort and inadequate communication. The agency stated, however, that improvements in internal coordination would be considered. In our discussion of alternative locations, we considered several existing agencies within HHS and did not mean to imply that responsibility should be given to a new office or agency, although that is an option. We have added the word "existing" to the phrase "new federal entity or existing entities" to clarify our intent. Nevertheless, the key point remains unchanged: There is no office or formal program in HHS charged with responsibility for basic research and development of quality assurance methods that would bridge the gap between clinical research and ongoing quality assurance programs in the manner we have specified. We have briefly outlined five possible locations for quality assurance research and development activities. Each offers advantages and disadvantages; any configuration would require more funding than is currently being spent. However, the difficulties involved in structuring a Developing a Medicare Quality quality assurance research and evaluation program do not, in our opinion, outweigh its potential benefits. Such an initiative would be an essential first step in developing an improved quality review system that can safeguard the health care of Medicare beneficiaries. In view of these considerations, the Subcommittee on Health of (1) Examine options for short-term improvements in the We would also like GAO to develop recommendations con- |