Medicare and Medicaid:

More Information Exchange Could Improve Detection of Substandard Care

HRD-90-29: Published: Mar 7, 1990. Publicly Released: Mar 7, 1990.

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GAO provided information on the Health Care Financing Administration's (HCFA) implementation of a recommendation that it develop guidelines to coordinate reporting on Medicaid and Medicare quality of care.

GAO found that: (1) review entities, including insurance carriers and peer review organizations (PRO), did not routinely exchange information about problem physicians; (2) officials agreed that data exchange would be useful; and (3) there were no statutory provisions that would prevent data exchange. GAO also found that HCFA: (1) proposed an amendment requiring PRO to routinely disclose information to licensing boards and accrediting bodies when submitting sanctioning reports; (2) required PRO to release certain information upon request; and (3) required PRO to routinely supply provider information to review entities and state licensing boards.

Recommendation for Executive Action

  1. Status: Closed - Implemented

    Comments: HCFA intends to require information exchange between carriers and PRO, and encourage such exchange between state Medicaid agencies and other entities. However, HCFA does not intend to require state Medicaid agencies to exchange information.

    Recommendation: The Administrator, HCFA, should require PRO, state Medicaid agencies, and carriers to routinely exchange information about physicians who provide unnecessary or poor-quality care. This could be accomplished through regulation and by including provisions requiring such exchanges in PRO and carrier contracts, requiring similar provisions in Medicaid state plans, and giving guidance to those entities clarifying the conditions under which such exchanges are permitted.

    Agency Affected: Department of Health and Human Services: Health Care Financing Administration


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