Medicare:

Improving Quality of Care Assessment and Assurance

PEMD-88-10: Published: May 2, 1988. Publicly Released: May 2, 1988.

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In response to a congressional request, GAO reviewed: (1) the Health Care Financing Administration's (HCFA) medical review systems for measuring and monitoring Medicare quality of care; and (2) quality assessment research and evaluation within the Department of Health and Human Services (HHS).

GAO found that: (1) there was no legislative requirement for nationally representative information on levels of quality or problems related to quality of care in covered services or on the overall health care provided; (2) HCFA oversight of carriers', intermediaries', and peer review organizations' (PRO) medical review activities focused only on whether they met contract specifications, rather than their effectiveness in identifying quality problems; (3) although carriers, intermediaries, and PRO devised systems for identifying and addressing particular types of quality problems, they had not coordinated their efforts; (4) because there was no information available to document how the review efforts were working, it was not known whether PRO effectively identified and corrected quality-of-care problems; (5) HCFA had no comparative information on the effectiveness of the quality review methods used for health maintenance organizations (HMO) and competitive medical plans (CMP); (6) HCFA did not require claims processors to include diagnostic information in their Medicare Part B billing forms or to enter the information into the billing files; (7) since the SuperPRO contractor did not adequately record the reasons for its random selections of PRO case reviews, the PRO data were not comparable or nationally representative; and (8) HHS had no clear strategy or organizational structure for integrating information on the quality of health care provided to Medicare beneficiaries or for developing methods and knowledge to meet future needs.

Matter for Congressional Consideration

  1. Status: Closed - Implemented

    Comments: AHCPR was established to pursue effectiveness research. The 1990 IOM report underscored the need for more systematic and comprehensive quality assurance under Medicare. No action has been taken.

    Matter: The House Committee on Ways and Means, Health Subcommittee, may wish to 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.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: HHS considers regional office oversight an adequate substitute.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to develop formal guidelines to coordinate the systematic and timely reporting by carriers and intermediaries to PRO of possible problems with the quality of care provided in ambulatory and posthospital care settings identified in medical reviews. These guidelines should ensure that: (1) intermediaries report directly to PRO, as well as HCFA, all cases where possible problems of premature or inappropriate hospital discharge may exist, including cases where Medicare coverage for skilled-nursing-facility or home health services has been denied to patients who may nevertheless have extensive care needs; and (2) information about possible quality-of-care problems uncovered by carriers is routinely shared with PRO.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Not Implemented

    Comments: It has been more than 3 years since the report was issued. There is no prospect of further agency implementation.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to fund additional studies to analyze the comparative effectiveness of particular PRO review methods, and the utility of current methods for establishing PRO quality objectives. These analyses should include assessments of whether different written review criteria or protocols generate significantly different rates of problems identified, and whether the identification of problems using these methods leads to significant changes in the incidence of quality problems over time.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Not Implemented

    Comments: It has been more than 3 years since the report was issued. There is no prospect of further agency implementation.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to initiate studies to assess the strengths and weaknesses of the current assignment of responsibilities among carriers, intermediaries, and PRO with respect to processing and screening Medicare claims data and performing medical reviews to identify quality-of-care problems and substandard providers and suppliers. These studies should specifically examine whether a realignment of responsibilities could improve the efficiency and effectiveness of Medicare quality review activities.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Not Implemented

    Comments: It has been more than 3 years since the report was issued. There is no prospect of further agency implementation.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to develop comparative information on the effectiveness of the quality review methods used by PRO reviewing quality of care in Medicare HMO and CMP. These studies should also produce comparative information on the overall levels of quality of care provided in participating HMO and CMP. This would require the collection of standard information on the use of services and health care outcomes across plans.

    Agency Affected: Department of Health and Human Services

  5. Status: Closed - Implemented

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to require that physicians include written descriptions and ICD-9-CM diagnosis codes on Part B claims, that this information be included in the carrier claims processing system, and that it be included in the Part B Medicare annual data file and the Medicare automated data retrieval system files.

    Agency Affected: Department of Health and Human Services

  6. Status: Closed - Not Implemented

    Comments: HHS does not see the utility of documenting the extent of data errors.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to require PRO, intermediaries, and carriers to routinely document and report incidents in which key data elements required for monitoring the quality of care are inaccurate. In particular, errors in mortality (date of death) and discharge destination, as well as all diagnostic and procedure data (not limited to diagnostic-related group assignment) should be monitored. Tracking of errors in the source and type of admission data fields should also be considered.

    Agency Affected: Department of Health and Human Services

  7. Status: Closed - Implemented

    Comments: The new HCFA database for PRO reviews includes "reason for selection", which identifies cases selected randomly. This datum is also included in SuperPRO data files.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to modify the scope of work of the SuperPRO contract to provide that the case selection methods ensure that those cases selected for random review by PRO are identifiable and that a nationally representative sample of cases can be constructed from the SuperPRO files for each review cycle.

    Agency Affected: Department of Health and Human Services

  8. Status: Closed - Not Implemented

    Comments: It has been more than 3 years since the report was issued. There is no prospect of further agency implementation.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to assign a high priority to completing the development of a central long-term care data system, including nationally representative data on the health care status, care needs, and health care outcomes of nursing home residents. In addition, these efforts should be coordinated with developing a similar data resource, drawing on survey and certification data for other subacute care facilities, especially home health agencies.

    Agency Affected: Department of Health and Human Services

  9. Status: Closed - Not Implemented

    Comments: Responsible HHS officials view these screens as serving an exclusively cost-saving function.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to assess the comparative effectiveness of carrier and intermediary screens and profiles as means to identify inappropriate and substandard quality care, as well as recover Medicare overpayments.

    Agency Affected: Department of Health and Human Services

 

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