Medicare: Increased HMO Oversight Could Improve Quality and Access to Care
HEHS-95-155
Published: Aug 03, 1995. Publicly Released: Aug 04, 1995.
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Highlights
Pursuant to a congressional request, GAO reviewed federal oversight of health maintenance organizations (HMO) that enroll Medicare beneficiaries, focusing on: (1) the Health Care Financing Administration's (HCFA) monitoring of HMO compliance with federal quality assurance standards; (2) HCFA enforcement actions against HMO that do not meet federal standards; (3) the process available to beneficiaries to appeal HMO decisions to deny care; and (4) approaches the private sector is taking to assure HMO beneficiaries of quality care.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to routinely publish: (1) comparative data it collects on HMO such as complaint rates, disenrollment rates, and rates and outcomes of appeals; and (2) the results of its investigations or any findings of noncompliance by HMO. |
The Balanced Budget Act of 1997 incorporated GAO's recommendation, specifically mandating that the Secretary provide to beneficiaries comparative information on disenrollments, and plans' recent records of compliance with legally mandated requirements, as well as other quality and performance indicators to the extent available. HCFA has begun collecting other quality and performance information for the first time, in the form of HEDIS (Health Plan & Employer Data & Information Set), indicators of the frequency of specific preventative medical services. HCFA plans to begin disseminating some of this information in 1998.
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| Department of Health and Human Services | The Secretary of Health and Human Services should direct HCFA to verify the effective operation of all HMO quality assurance and utilization management practices, by applying sufficient trained staff during routine monitoring, and integrating peer review organization findings into HCFA compliance monitoring reviews. |
HCFA has hired clinical staff with quality assurance and utilization management (QA/UM) expertise to oversee and conduct QA/UM audits of Medicare+Choice (M+C) contractors. The agency has developed a partnership with the Medicare+Choice Quality Review Organizations to provide technical assistance (utilizing one standard assessment tool) to its regional office staff doing evaluations of M+C organizations' quality assessment/performance improvement projects. Further, HCFA has incorporated into the M+C final rules the QA/UM deeming standards that were required under the BBA and BBRA.
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| Department of Health and Human Services | The Secretary of Health and Human Services should direct HCFA to explore further options to streamline the appeal process. |
Interim final regulations for an expedited appeal process were issued April 30, 1997, citing GAO's study as supporting the need for an expedited process. HCFA issued implementation guidance to HMOs on July 22, 1997, and is implementing the new, expedited process with its risk-contract HMOs.
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Appellate procedureContract oversightData collectionHealth care servicesHealth maintenance organizationsHealth resources utilizationLaw enforcementMedicareNoncompliancePrivate sector practicesQuality assurance