Medicare PROs:

Extreme Variation in Organizational Structure and Activities

PEMD-89-7FS: Published: Nov 8, 1988. Publicly Released: Nov 8, 1988.

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Pursuant to a congressional request, GAO provided information regarding the Health Care Financing Administration's Utilization and Quality Control Peer Review Organizations (PRO) Program, which provides nurse and physician reviews of Medicare patients' hospital records, focusing on the organizations': (1) characteristics; (2) review activities; (3) objectives and interventions; and (4) relationships with other health and consumer groups.

GAO found that at least half of PRO: (1) had representatives of state medical societies, hospital associations, and consumer groups on their boards of directors; (2) reported revenue from non-Medicare sources, such as reviews for Medicaid recipient care or for insurance companies; (3) typically hired registered nurses as their review coordinators; (4) experienced significant review coordinator turnover; (5) typically hired board-certified specialists for their physician-advisors; (6) received attending physician input for most case reviews; and (7) did not share any of their review information with state licensing boards. GAO also found that PRO: (1) on the average, identified about 22 percent of cases as having potential quality problems and confirmed about 38 percent of those cases as having problems; (2) varied significantly in quality problem identification and confirmation rates; (3) generally had global objectives to reduce the incidence of certain health care problems, although a few PRO concentrated on specific physicians or hospitals; (4) typically used a notification letter to inform physicians of quality problems and less frequently intervened with measures such as intensive review of subsequent cases, continuing education, and counseling; and (5) on the average, confirmed that there were problems in about 4 percent of case reviews initiated by Medicare recipients' complaints.

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