6
Federal Quality Assurance Programs for Medicare

After creating the Medicare program in 1965, Congress mandated efforts for organized quality assurance for Medicare beneficiaries. Successive federal activities have included Experimental Medical Care Review Organizations (EMCROs), Professional Standards Review Organizations (PSROs), and Utilization and Quality Control Peer Review Organizations (PROs). Antedating these efforts were “foundations for medical care,” a physician-based movement begun in California in the 1950s. These community-centered organizations of participating physicians monitored the use and quality of both hospital and ambulatory care services before payment by fiscal intermediaries (FIs) (Egdahl, 1973; Harrington, 1973; Lohr et al., 1981).

These activities (and the growth of the Joint Commission on Accreditation of Hospitals) were the most visible examples of a grassroots professional interest in the quality of medical care delivery that emerged following the Second World War. In contemplating the structure and purposes of a quality assurance system for Medicare that will carry into the 21st century, one should realize that organized quality assurance arose initially as a professional effort and that it has a modern-day history half a century old.

The nation’s health care providers have devised many ways to assure the quality of health care.1 The Medicare program has used two main approaches. One is Medicare Conditions of Participation and the closely linked accreditation activities of the Joint Commission on Accreditation of Healthcare Organizations. The second is the program’s successive Medicare quality review programs, which are discussed in this chapter. The sources of information include literature reviews, extensive site visits around the country, documents and staff briefings from the Health Care Financing Administration (HCFA), interviews with representatives of relevant organizations and institutions, and personal experience of members of the IOM committee.



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Medicare: A Strategy for Quality Assurance - Volume I 6 Federal Quality Assurance Programs for Medicare After creating the Medicare program in 1965, Congress mandated efforts for organized quality assurance for Medicare beneficiaries. Successive federal activities have included Experimental Medical Care Review Organizations (EMCROs), Professional Standards Review Organizations (PSROs), and Utilization and Quality Control Peer Review Organizations (PROs). Antedating these efforts were “foundations for medical care,” a physician-based movement begun in California in the 1950s. These community-centered organizations of participating physicians monitored the use and quality of both hospital and ambulatory care services before payment by fiscal intermediaries (FIs) (Egdahl, 1973; Harrington, 1973; Lohr et al., 1981). These activities (and the growth of the Joint Commission on Accreditation of Hospitals) were the most visible examples of a grassroots professional interest in the quality of medical care delivery that emerged following the Second World War. In contemplating the structure and purposes of a quality assurance system for Medicare that will carry into the 21st century, one should realize that organized quality assurance arose initially as a professional effort and that it has a modern-day history half a century old. The nation’s health care providers have devised many ways to assure the quality of health care.1 The Medicare program has used two main approaches. One is Medicare Conditions of Participation and the closely linked accreditation activities of the Joint Commission on Accreditation of Healthcare Organizations. The second is the program’s successive Medicare quality review programs, which are discussed in this chapter. The sources of information include literature reviews, extensive site visits around the country, documents and staff briefings from the Health Care Financing Administration (HCFA), interviews with representatives of relevant organizations and institutions, and personal experience of members of the IOM committee.

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Medicare: A Strategy for Quality Assurance - Volume I The federal programs were fashioned to address incentives of the prevailing financing mechanisms for health care. For instance, when cost-based reimbursement was the predominant mode of hospital payment, utilization review to detect overuse of care had a key place in peer review efforts such as the PSRO program. Prospective payment prompts more attention to underuse and quality of care, as seen in recent activities of the PRO program. Nevertheless, utilization review and quality assurance are closely linked activities; both have been and will continue to be important in any program intended to assure the quality of care for the elderly. In designing the strategy for a new quality assurance program for Medicare (Chapter 12), we hope to create a program with the flexibility and appropriate tools that can respond to whatever incentives emerge from changing Medicare financing and reimbursement schemes. To lay the groundwork for such a program, we here examine past and existing quality assurance efforts for Medicare. EXPERIMENTAL MEDICAL CARE REVIEW ORGANIZATIONS Experimental Medical Care Review Organizations (EMCROs) were voluntary associations of physicians who reviewed inpatient and ambulatory services paid for by Medicare and Medicaid. The program, in existence between 1970 and 1975, was administered and funded by the National Center for Health Services Research and Development. Far more a research and development effort than an operational one, the EMCRO mission was to encourage physicians to work together and to upgrade methods for assessing and assuring quality of care. EMCROs were concerned with both inpatient and ambulatory care. Although no comprehensive evaluation of the EMCRO program was ever done, analyses of data and activities of the New Mexico EMCRO documented important impacts of the program on the appropriate use of injectable drugs and on the quality of ambulatory care in the state’s Medicaid program (Lohr et al., 1980). Those results were obtained through a dual approach that emphasized education (development and promulgation of injection guidelines) and economic sanctions (denial of payments for inappropriate services). EMCROs were essentially a prototype for PSROs, established about midway through the EMCRO program. PROFESSIONAL STANDARDS REVIEW ORGANIZATIONS Purpose and Structure Professional Standards Review Organizations (PSROs) were established by the Social Security Amendments of 1972 (P.L. 92–603) to assure that

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Medicare: A Strategy for Quality Assurance - Volume I physicians and institutions met their Medicare obligations; such obligations required that services provided or proposed to be provided to Medicare beneficiaries were medically necessary, of a quality that met local professionally recognized standards, and were provided in the most economical manner consistent with quality of care (Goran et al., 1975; Blum et al., 1977). Congress intended PSROs to lower public expenditures for medical care, to counter fee-for-service incentives toward overuse of services, and to help to ensure the quality of care. PSROs were voluntary, not-for-profit, local physician organizations; each PSRO area covered approximately 35 hospitals and 2,000 to 3,000 physicians, on average, although the range was quite broad. The original PSRO areas numbered 203 (195 in 1977 and thereafter). By mid-1981, of these 195 designated areas, 182 had funded PSROs; of those, 47 were “fully designated,” 132 were “conditional,” and 3 were in the planning stage. Consequently, length of continuous operation, skills, and experience varied considerably across PSROs, and the history of the fully operational program was relatively short. The program was administered by HCFA’s Health Standards and Quality Bureau (HSQB) in the Department of Health, Education and Welfare [later Health and Human Services (DHHS)]. HSQB used a complicated system of annual grants to PSRO entities consisting partly of congressionally appropriated general revenues and partly of Medicare Trust Fund monies. Aspects of the PSRO Program of Importance to the PRO Program Briefly, PSROs carried out the following activities: hospital utilization review, development of hospital discharge data (the PSRO Hospital Discharge Data Set), profile analysis, Medical Care Evaluation (MCE) studies and Quality Review Studies, and review of care rendered in other settings (ancillary services, nursing home care, and ambulatory care). Some PSROs contracted to do utilization review for private firms and municipal governments. A few PSROs collaborated in research studies (Chassin and McCue, 1986) and studies of variations in hospital use. Utilization Review Hospital utilization review was viewed as distinct from quality assurance and was given highest priority by PSROs. It usually took the form of preadmission certification for elective hospital admissions, certification of nonelective admissions (within three days of admission), and continued stay recertification; both concurrent and retrospective review was done. One lesson of the PSRO program was that 100 percent utilization review was excessive, and PSROs came to “focus out” about 50 percent of the admis-

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Medicare: A Strategy for Quality Assurance - Volume I sions they might have reviewed at the start of the program. No consensus was ever reached, however, either on the appropriate criteria for such focusing out or on the sample sizes needed to achieve cost-effective utilization review. Issues of concurrent versus retrospective review and of focusing out providers or particular types of services are as pertinent for the PRO program as they were a decade ago. Profile Analysis Profiling is a form of retrospective review of patient care data to identify patterns of care over a defined period of time. Profiles can be constructed by groups of patients (e.g., diagnostic group), by provider (e.g., hospital or nursing home), or by practitioner (e.g., physician) to determine rates of use of services such as admissions or specific procedures and lengths of stay over time. They can be used to identify “outliers” that fall outside established standards of appropriate care, such as excessively long hospital stays; such providers or practitioners can then be targeted for closer scrutiny or corrective interventions. This targeting was the principal application of profiling in the PSRO program, and profile analysis continues to be a major tool for review.2 Quality of Care Quality-related activities of the PSRO program included MCE studies, which were audits based on medical records of locally identified quality problems, typically related to specific diagnoses, technologies, or procedures. MCEs were done either by individual (delegated) hospitals or by PSROs for nondelegated hospitals or for groups of hospitals. The numbers of MCEs done by (or for) any one hospital were determined partly in conjunction with Joint Commission requirements. Toward the end of the PSRO program, MCEs evolved into Quality Review Studies, which were expected to rely on data beyond the medical record, identify a broader set of topics for study, and document more fully the impact of the review activity on quality of care. Many innovative PSROs did area-wide MCEs that permitted hospitals to compare their audit outcomes with those of their peers; this was considered a valuable quality assurance mechanism. The difficulty, however, of demonstrating in quantitative terms the impact of MCEs (as contrasted with simply enumerating the number of MCEs conducted) contributed to the inability of the PSRO program to document a meaningful effect on quality of care. Studies of the MCE variety still dominate the quality assurance efforts in hospitals, owing in part to the familiarity of hospital staffs with this activity, but they are not part of the PRO scope of work.

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Medicare: A Strategy for Quality Assurance - Volume I Other Efforts Often lost in the historical account of the PSRO program is that some PSROs embarked on a considerably broader review agenda than simply hospital utilization review and MCEs. Perhaps as many as one-third of PSROs became involved in hospital-related ancillary services review (e.g., radiology, medications, and laboratory tests), although budget constraints for this were severe. The ancillary services experience relates directly to the procedure-oriented review the PROs do now, but in some respects the PSRO experience represents a broader set of health care services. Still other PSROs reviewed care in long-term-care facilities; although budget cuts curtailed these efforts, at the peak about 55 PSRO projects were underway in such facilities. Ten PSRO demonstration projects that reviewed nursing home care (which included pre-admission, admission, and continued stay review, quality assurance activities, MCEs, and data systems development) were given special attention in the late 1970s (Kane et al., 1979). Finally, a few PSROs were involved in various ambulatory care review projects (e.g., physician office care as distinguished from ambulatory surgical procedures done in hospitals or free-standing clinics). Evaluations of these activities were inconclusive about dollar savings to the Medicare program (the key evaluative criterion), and PSROs made little progress in this arena, for several reasons. In the first place, ambulatory care is harder to review than inpatient care; it is more dispersed, involves more providers and sites, reflects many more patient-provider encounters, and has less well-developed methods. Second, the Medicare insurance claims forms of the day would not have provided adequate information for this endeavor. Third, physicians a decade ago were reluctant to facilitate review of their private office practice records. Fourth, the costs of outpatient care were less significant before the Medicare prospective payment system and the considerable shift of hospital care to the nonhospital setting, and ambulatory care offered less opportunity for meaningful savings than hospital care; given that cost control was the principal operational task of PSROs, they had less incentive to attempt ambulatory review. Finally, the program budgets for ambulatory review were quite low. Delegation One controversial aspect of the PSRO program was its ability—more accurately, its mandate and related budgetary incentives—to “delegate” certain quality assurance and utilization review functions to individual hospitals judged to be capable of carrying them out. Delegated hospital review was funded through negotiated budgets between the PSRO and the individ-

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Medicare: A Strategy for Quality Assurance - Volume I ual hospital. PSROs monitored the performance of delegated hospitals but usually did no ongoing data collection or abstracting in those facilities. By contrast, they did all such tasks directly in nondelegated institutions. This form of delegation was not judged particularly successful at the time (HCFA, 1980). PSROs lacked administrative and financial control of delegated hospital review. For instance, removing delegated status was administratively very difficult. Further, delegated review costs were simply passed on to the Medicare Trust Fund, whereas nondelegated review was a PSRO line item in the federal budget; thus, the pressure to delegate was very great. Finally, delegated hospitals determined their own procedures, identified their own MCE topics, and in other ways operated quite independently of one another; this complicated the job of evaluating the impact of the program as a whole. In an environment in which the majority of physicians and hospitals tolerated rather than enthusiastically supported the PSRO program, the performance of delegated hospitals was often a perfunctory exercise in “paper compliance.” Another issue was the mismatch between the expectation that the PSRO program act as a regulatory control mechanism for an activity—namely, health care delivery—from which they were twice removed; that is, they neither delivered health care directly nor, for delegated hospitals, directly reviewed the performance of caregivers. This mirrored the great divergence in expectations for the PSRO program generally—namely, the congressional expectations that they were getting a cost-control program, the PSRO belief that they were doing quality assurance, and HCFA’s view that the program did both. The end result was that, as PSROs were phased out and PROs phased in, HCFA regulations eliminated delegation as a program option. Costs According to the 1979 HCFA evaluation (HCFA, 1980), the mean dollar cost of hospital-based review per discharge in 1978 (i.e., fiscal year (FY) 1979, when program costs were $147.2 million) was $13.68 for the review activity itself and $7.10 for management and support tasks. The median total review cost for FY 1979 was $12.91, a figure the HCFA evaluation noted was “considerably greater than the target of $8.70” (HCFA, 1980, p. 92). Mean costs per discharge differed markedly by type of review: $8.81 for concurrent review, $1.28 for MCE review, and $3.61 for areawide review; the highest and lowest cost ranges around these averages were fairly wide.3 Costs differed by who did the review. Delegated review (e.g., when delegated hospitals did concurrent hospital admission and continued-stay review themselves) was less expensive on a per-discharge basis than was

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Medicare: A Strategy for Quality Assurance - Volume I nondelegated review; for instance, the median concurrent review cost for the larger PSROs (those responsible for 50,000 or more discharges) was $6.93 for delegated hospitals and $10.56 for nondelegated hospitals. In short, costs of review were extremely variable (as they remain in the PRO program). Total PSRO funding rose from $4.3 million in 1973 to $173.7 million in 1981 (CBO, 1981). Funding was unstable over the period; for instance, it increased almost 43 percent between FY 1977 and FY 1978 but just under 2 percent between FY 1978 and FY 1979 and not quite 4 percent between FY 1979 and FY 1980. Medicare expenditures during the PSRO program ranged from about $9.5 billion in FY 1973 to $42.5 billion in FY 1981. Hospital insurance (Part A) outlays alone were $6.8 and $29.3 billions, respectively (Committee on Ways and Means, 1989). Taking total outlays as the denominator, PSRO program costs by the end of the program amounted to only about one-half of 1 percent (about 0.45 percent) of outlays; the figures reach about 0.7 percent if only Part A expenditures are used as the base. As will be seen, PRO funding has been equally tight, if not more so. Additional Aspects of the PSRO Program The National Council The PSRO legislation provided for a National Professional Standards Review Council, appointed by the executive branch. It consisted of 11 physicians not in the federal government who could represent or were recommended by practicing physicians, consumer groups, and other health care interests. The Council was charged with reporting at least annually to the Secretary of the Department of Health, Education and Welfare and to the Congress on its activities; the report was supposed to review the effectiveness and comparative performance of PSRO operations, develop recommendations concerning ways that the program might be designed more effectively, and provide comparative data indicating the results of review activities. At the time, the Council was regarded with some suspicion because its rather ambiguous charge was seen as a threat to the local autonomy of physicians and as an opening wedge in the establishment of national or model standards of care (Blumstein, 1976), all issues of vastly greater sensitivity 15 years ago than now. In retrospect, the Council was not demonstrably successful in shaping the long-term policies of the program toward quality of care and away from cost containment. The economic and political forces pushing for control of utilization and costs were too strong. The Council also made little progress toward developing standards of care; again, the climate for such efforts was not receptive.

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Medicare: A Strategy for Quality Assurance - Volume I The Council’s value was as a regular public forum for discussion of issues pertinent to the PSRO program. The public meetings were extremely well attended, fostered both formal and informal interaction among the Council, public attendees, and staff, and permitted timely information to be published in the lay press concerning program direction. The Council provided, albeit imperfectly, for some accountability of the program, and it gave some opportunity for early review and consideration of program plans and advice to HCFA by a well-disposed, but external, group of experts. Sanctions and Regulatory Orientation PSROs were perceived as essentially regulatory mechanisms for controlling medical practice. HCFA (1980), for instance, characterized PSROs as “formalized externally authorized and mandated local physician organizations expected to function as a regulatory system exercising control via performance evaluations tied to financial and professional sanctions” (p. 141). The PSRO program was hampered by its relatively limited ability to act on this presumed regulatory power and to bring or recommend sanctions against providers. Aggressive PSROs initiated sanctions generally the way PROs do now, except that sanctions were pursued internally at HCFA, not by the Office of Inspector General (OIG), and with similar results (e.g., very high costs and reversals at the level of administrative law judges). Furthermore, hospitals and other providers were assumed to have a favorable “waiver of liability” status. PSROs could only recommend to the relevant FI that the waiver be revoked, but the decision to do so resided with the FI.4 In principle, the PROs have a considerably stronger hand in sanctioning physicians and hospitals than did the PSROs, in part because sanctions are now pursued through the OIG and in part because the waiver of liability issue has been muted. In practice (as will be seen), their regulatory power has not been demonstrably enhanced. To gain the acceptance of the provider community in the early years, some congressional supporters and some executive branch directors of the program emphasized the quality-of-care (rather than the cost-control) thrust of the program (Blumstein, 1976). In quality assurance terms, this translated into an “educational” rather than a “regulatory” program. The ambiguity inherent in an “educational-regulatory” stance was never successfully resolved. More importantly, a considerable ambiguity arose in the conflicting emphases on containing costs while maintaining quality. The framers of the PSRO legislation and program intended primarily that it lower the inappropriate or unnecessary use of services, as the alarming increase in the cost of medical care at that time was assumed to arise largely from overuse of services. Evaluations at the time were focused mainly on PSRO impacts on costs; for instance, from the General Accounting Office (GAO) in 1979

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Medicare: A Strategy for Quality Assurance - Volume I came Problems with Evaluating the Cost Effectiveness of Professional Standards Review Organizations, which was focused exclusively on savings in costs and patient hospital days, and from the Congressional Budget Office (CBO) in 1981 came The Impact of PSROs on Health-Care Costs. Evaluations of PSRO impacts on quality of care were never accorded similar status or conducted with equivalent sophistication. A major lesson of the PSRO program was that the conflict between using such agents simultaneously to contain costs and to maintain quality will almost surely short-change the latter unless strong programmatic steps are taken to protect and emphasize it. Impact of the PSRO Program The net impact of PSROs on utilization, expenditures, or quality remains uncertain. Several evaluations of the PSRO program conducted in the late 1970s yielded contradictory findings (e.g., CBO, 1979, 1981; GAO, 1979; HCFA, 1980). Overall, the PSRO program probably saved as many resources as it consumed, but in an era of rapidly escalating health (and Medicare) expenditures, this was not perceived as an adequate level of performance (Lohr, 1985). PSROs did appear to have a slight positive impact on quality of care as measured by documented changes in medical practices rather than by dollar savings (HCFA, 1980; AAPSRO, 1981). Again, however, in an environment concerned chiefly with rising expenditures, these effects were not persuasive as regards the success of the PSRO program. Among the conclusions that might be drawn about the PSRO experience were the following. Monitoring and evaluating a program that operates through almost 200 individual organizations is difficult. Budget constraints, although a fact of life, will compromise the effectiveness of such a program. Delegating review authority, when not accompanied by the power to remove delegation promptly for poor performance, can undermine the effectiveness of a program. Finally, it is exceedingly difficult to combine cost and quality functions in one organization, especially when expectations and evaluations of the program concentrate on cost issues. Movement to a New Program Disappointment at the limited effectiveness of the PSRO program prompted calls for its abolition or restructuring, and it was phased out in the early 1980s as the PRO program was slowly put into place. Despite rhetorical emphasis on assuring quality of care, the principal focus of the new PRO program initially remained on use of services and costs. In other words, philosophically not much changed.

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Medicare: A Strategy for Quality Assurance - Volume I Structurally, much about the program was revamped. The ability of PROs to act against overuse of services and to curtail expenditures was strengthened (relative to the PSRO program), and administrative and financing arrangements were changed so that the program could, at least in theory, be better managed at the federal level. Nevertheless, many of the difficulties facing the PSRO program remained, not the least of them being the mismatch between the call for attention to quality of care and the funding for activities designed to control utilization and expenditures. In this vein, it is well to remember that the full name of the PROs is the Utilization and Quality Control Peer Review Organizations. UTILIZATION AND QUALITY CONTROL PEER REVIEW ORGANIZATIONS (PROs) The PRO program was a congressional response to considerable discouragement over the performance and impact of the PSRO program as well as an effort to design a system to fit the diagnosis-related group (DRG) prospective payment system (PPS) for hospital care that began in October 1983. Like PSROs, PROs are supposed to ensure that services rendered through Medicare are necessary, appropriate, and of high quality. PRO activities, however, extend widely into many aspects of the administration of Medicare program. They are by no means confined to issues relating to use, costs, or quality of care, and certainly not just to ensuring the technical quality of care rendered to beneficiaries. PROs serve different purposes for different parties, not all of whom have the same interests or concerns. Given the hostility and disappointment registered about a PSRO program that was vastly less burdened with administrative and outreach responsibilities, this increase in the responsibilities and visibility of the program created to replace PSROs is somewhat ironic. PROs carry out their complex assignments on a total annual budget that now approximates $300 million per year—a sum that seems large in the abstract but in fact accounts for about 0.3 percent of Medicare Part A and Part B expenditures. Thus, understanding the role and potential impact of PROs on assuring quality of care for Medicare calls for appreciating the many and complex tasks they have been assigned, the specificity of the contract requirements that govern those tasks, and the limited resources they can bring to bear on the required activities. The remainder of this chapter discusses these topics. PRO Legislation and Regulations Several pieces of legislation governed the development of the PRO program. The key act was the Tax Equity and Fiscal Responsibility Act (TEFRA)

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Medicare: A Strategy for Quality Assurance - Volume I of 1982 [more specifically, the Peer Review Improvement Act, Title I, Subtitle C of TERRA (P.L. 97–248)], which amended Part B of Title XI of the Social Security Act. Other important legislation included the Social Security Amendments of 1983 (P.L. 98–21), the Deficit Reduction Act (DEFRA) of 1984 (P.L. 98–369), the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (P.L. 99–272), the Omnibus Budget Reconciliation Acts (OBRA) of 1986 and 1987 (P.L. 99–509 and P.L. 100–203), and the Medicare and Medicaid Patient Program Protection Act of 1987 (P.L. 93–100). Apart from legislation, numerous regulations and other directives govern the administration and operation of the PROs. The Administrative Procedure Act (APA) requires that regulations be promulgated through notice and comment rulemaking procedures. HCFA follows the APA procedures in some instances. As an adjunct to the cumbersome and often lengthy public rulemaking mechanism, the agency also relies extensively on PRO Manual transmittals, contracts and contract modifications, and other, less formal instructions. PRO Organizational Characteristics PSRO regions were consolidated into 54 areas (all the states, the District of Columbia, Puerto Rico, the Virgin Islands, and a combined area of American Samoa, Guam, and the Commonwealth of the Northern Marianas). Beginning roughly in 1986, eight PROs covered two areas, and one PRO covered three areas.5 Congress tried to retain some semblance of “local” peer review. To qualify as a PRO, the statewide organizations must demonstrate sponsorship by being composed of at least 10 percent of the physicians practicing in the area (known as a physician-sponsored organization), or it must have available for PRO review at least one physician in every generally recognized specialty in the area (known as a physician-access organization); the former have priority. Third-party payers can obtain PRO contracts only if no other eligible organization is available. A PRO may not be a health care facility or other entity subject to review, it must have at least one consumer representative on its governing board, and it must operate with objectivity and without apparent or real conflict of interest. PRO Contracts PROs are financed through competitively awarded contracts. The very complex set of review and intervention tasks are specified in great detail in the “Scope of Work” (SOW) in the Request for Proposal for these contracts, and PRO performance is evaluated on the basis of how well they meet these

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Medicare: A Strategy for Quality Assurance - Volume I the quality of care of an appropriate range of health services, but definitional, operational, and strategic problems remain. We noted in Chapter 1 and elsewhere the importance of defining quality of care as a means of directing the efforts of a quality assurance program, and we have further emphasized the importance of health outcomes in that definition. Neither of those concepts is yet specifically tackled as part of the present PRO program. Third, the program should be focused much more single-mindedly on quality review and quality assurance, less on direct cost and utilization control, and even less on activities of at best peripheral utility to improving the quality of health care. Some current program activities, such as review of hospital notices of denial and the Important Message to Beneficiaries or aspects of beneficiary and community outreach, warrant explicit assessment and re-consideration in terms of their contribution to improving quality and in terms of whether they should be conducted “locally” or through a different national effort. Some activities might be conducted by other agents. For instance, the carriers might profile physician claims to detect aberrant patterns of practice, leaving “on-site” review of quality of care that requires clinical judgment to the quality assurance program. Beneficiary communications and outreach materials might be developed and disseminated at the federal level. Fourth, a more forceful emphasis on quality is especially important because the PRO program is not now in a good position to focus on important health outcomes, especially as broadly envisioned as in this report. It is also not well positioned to focus on populations (outside the small HMO and CMP enrollee population). Transforming the Medicare quality assurance program into one as heavily oriented toward patient well-being and population outcomes as intended by this committee will require considerable resources, sophisticated planning, and concentrated effort within the PRO and professional communities. Activities that do not obviously serve this central quality assurance purpose should be eliminated, downgraded, or moved to other agencies. For instance, one might envision much greater responsibility for claims analyses for FIs and carriers, with timely and substantial sharing of information on problem practitioners and providers to the Medicare quality assurance program. That program would, in turn, have much greater responsibility for the clinical aspects of quality review and assurance methods and for longitudinal patient outcomes. Fifth, some rethinking of the methods for doing nonhospital review is warranted. Reviewing “intervening care” for the HHA and SNF settings does not make much sense in either a conceptual or a statistical sense, and it has proven technically troublesome and unproductive; a considerable overhaul of post-acute review would be in order. In addition, the mismatch between the fee-for-service and the prepaid group practice sectors in ambu-

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Medicare: A Strategy for Quality Assurance - Volume I latory care review (both scope and methods) seems unfair and possibly counterproductive. Limitations of and uncertainties about the implementation of the HMO-CMP ambulatory care effort suggest that ending the present approaches and conducting pilot projects in both sectors to develop appropriate methods might be desirable. Sixth, the system of legislation, regulations, interpretative guidelines, transmittals, and so forth that comprise the rules governing the program has less public oversight and input than desirable. Moreover, the great complexity, confusion, and lack of uniformity in the program prompts questions as to how well agency planning, implementation, and oversight has served the congressional purposes for the program or the Medicare beneficiaries’ needs. The program needs to have a more open or public mechanism for program planning, oversight, evaluation, and accountability. Seventh, this committee has strongly endorsed a move to finding ways to emphasize positive achievements, to recognize good (and “excellent”) performance, and to reward providers and practitioners when they provide good quality care and mount successful quality assurance program. It has also emphasized that the Medicare quality assurance program should be able to identify and deal with poor performance. For the latter objective, a “quality intervention plan” with several types of interventions and sanctions has been developed. Although the new QIP procedures (especially sanctions) warrant some changes, generally it might be seen as a reasonable starting point for the regulatory aspects of the MPAQ. The program has little or no experience, however, with the former goal, namely recognizing and rewarding good performance. One strategy is to reduce the level of external review for good performers (and perhaps concomitantly to increase the level of internal review). The acceptance of and results of limited review in the HMO and CMP plans to date suggest that that approach does not provide a satisfactory model. Although delegation in the old PSRO sense may not be an attractive plan and is actively opposed by some in the peer review and provider communities, some form of delegation clearly has to be contemplated. This is tantamount to saying that relying on hospitals to conduct chart review, with external oversight from PROs, deserves careful consideration and testing. Virtually no information is available on more radical ideas, such as rewarding good performance with public acknowledgement or financial payments, certainly not in the PRO program. Thus, much attention will have to be given to achieving the related goals of meaningfully recognizing the provision of good quality care (or of maintaining a good internal quality assurance program) and reducing the level and intensity of external review. Greater public and expert inputs into and oversight of such efforts are desirable. Eighth, it is unclear that the present approach to “peer review” provides

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Medicare: A Strategy for Quality Assurance - Volume I the PROs with state-of-the-art professional knowledge or the highest levels of specialist expertise. Several factors militate against involvement of busy private practice specialists in PRO review, such as the low reimbursements for review activities (especially relative to what is paid by HCFA Regional Offices or other review entities), distaste for the “quality denial letter,” and knowledge of the frustrations inherent in certain PRO processes (such as review of high volumes of false-positive generic screen failures and the cumbersome sanctioning process). Lack of understanding of the need for specialist participation in developing and promulgating procedure-specific practice guidelines and prior-authorization criteria, and consequent lack of acceptance of the guidelines and criteria that PROs do develop, may also play a role. Finally, despite two decades of inspired leadership in the medical community in the quality assurance and peer review movement, many physicians remain suspicious of and hostile to PRO activities, continuing to perceive it at one and the same time as intrusive, arbitrary, and punitive—and fundamentally irrelevant to improving quality of care. Ninth, PROs individually and the program more generally do a poor job of documenting their impact on quality of care. They are therefore not in a good position either to defend their own record or to judge and comment on how well other organizations are doing. These issues call for much improved evaluation criteria and procedures, so that documented improvements in quality of care become significant parts of the scope of work on which PROs would be evaluated. This in turn argues for an in-depth review of past and impending SuperPRO efforts, of the contemplated “physician consultant” program, of the role of the Regional Offices, and similar evaluation schemes. A thorough review of the contracting mechanism itself and a re-consideration of the potential advantages of using the grant rather than the contracting mechanism is also in order, especially to the extent that the quality assurance agent should be focusing on “local” in addition to “national” problems. Tenth, two issues about PRO financing are important. The PRO program has been assigned a vast array of quality of care, utilization review, PPS implementation, and other responsibilities for the Medicare program. To meet these assignments, it has a budget that remains well under one-half of 1 percent of Medicare expenditures. This level of funding is no greater, proportionally, than it was for the PSRO program nearly a decade ago, yet the peer review program assignments have been appreciably expanded (not entirely for quality-of-care concerns, however). We view this overall investment in a program intended to monitor and improve the quality of care for the elderly as likely to be too low ever to accomplish the expected tasks adequately. We are also concerned that the mechanism of funding individual PROs through extraordinarily detailed contracts and contract modifications is too limiting; it seems to foster evaluations of contract performance

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Medicare: A Strategy for Quality Assurance - Volume I rather than impact on quality of care and to constrain innovation and flexibility to meet local conditions and problems. SUMMARY Since nearly the beginning of the Medicare program, the federal government has tried to ensure that services reimbursed through the program are medically necessary, appropriate, and of a quality that meets professionally established standards. The two main efforts in this arena were the PSRO and then the PRO program. These programs share some characteristics: They have adopted purposes and methods reflecting the expected incentives of the prevailing financing mechanisms of Medicare. They have been oriented more toward controlling utilization and costs than toward improving quality of care. Both attempted to preserve “local” and “peer” review. They have concentrated on inpatient care. Both programs have been funded at a rather anemic level (more or less one-half of 1 percent of Medicare expenditures). Both programs have produced a good deal of variability in review criteria, findings, and statistics, despite considerable detailed prescription (especially for the PROs) of their operations. Finally, neither program has been able satisfactorily to demonstrate an impact on quality of care for the elderly, in large part because their emphasis has been on cost and utilization control. The programs also differ in important ways: the PRO program has been fully operational far longer than the PSRO program was, and it has responsibilities related to implementation of Medicare’s PPS that the PSRO program could not have had. The PSRO program probably had more public oversight of its activities than the PRO program has had. The PSRO program was more local than the PRO program (e.g., 195 PSRO areas versus 54 PRO contracts today). PSROs were funded through grants, whereas PROs are awarded competitively bid contracts. Partly as a consequence of these two factors, the PSRO program was probably more flexible and responsive to local utilization and quality problems than the PRO program can be. The PSRO program attempted to implement a form of “delegated review” so as to reduce intrusive external efforts; the PRO program has been precluded from any form of delegated review, partly because of the perceived weakness of delegation as it was managed during the PSRO days. Finally, the PSRO program was subjected to more rigorous evaluation than the PRO program has been to date. Apart from these comparisons, the PRO program has some strengths that should be acknowledged. Most important may be that PROs have a committed and experienced group of physicians, nurse reviewers, and administrators with considerable expertise in the tasks needed to be accomplished by any present or future Medicare quality assurance program. Much of this

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Medicare: A Strategy for Quality Assurance - Volume I cadre of quality assurance experts came initially out of the PSRO and earlier peer review efforts. In addition, PROs can operate on the basis of better Medicare data sets than were available during PSRO days, and they have a considerable advantage in computer technology compared to the earlier program. The PRO program also has some limitations that would constrain its ability to fulfill the goals and objectives of a Medicare quality assurance program as envisioned by this committee and detailed in Chapter 12. These include its presently inadequate ability to address or to affect health outcomes for the elderly, the relative paucity of public oversight or accountability, and the enormous burden of conducting activities that are not demonstrably related to improving the quality of care or that involve tasks (such as public outreach) for which PROs do not have a comparative advantage. Other problems include the fuzzy legal status of sanctioning authority (for both PROs and the OIG), regulations that forbid or constrain innovation (such as alternative approaches to in-hospital chart review), and continuing difficulties with data sharing and data release. In designing a strategy for quality review and assurance for Medicare that will put in place a program to assure quality of care as it was defined in Chapter 1, this committee will thus attempt to build on the known capabilities of PROs and offset the perceived weaknesses. That program and the strategy for implementing it are discussed in Chapter 12. NOTES 1.   For more complete discussions of approaches to quality measurement and assurance other than those mounted by the Medicare program, see Chapter 9 and Volume II, Chapter 6. Chapter 5 and Volume II, Chapter 7, discuss Medicare Conditions of Participation more fully. Volume II, Chapter 8 provides a more complete description of the PRO program; later sections of this chapter rely heavily on lengthy excerpts and tables from that volume. 2.   Profiling can also be used to identify patterns of problems with the quality of care other than those related specifically to use of services, such as failures on generic screens or unexpected patient deaths. This is one application of profiling found in the present PRO program. 3.   The HCFA evaluation cautioned strenuously against drawing inferences from these data, which are per discharge, about costs per review, because the PSRO program compiled no comprehensive information on the number of reviews that were conducted by hospitals or by PSROs. 4.   Waiver of liability meant that unless a hospital “knew or could reasonably have been expected to know” that the care it was providing was unnecessary, the costs of that care would still be reimbursed and the hospital was not financially liable. Only if the hospital’s waiver was revoked would it become financially at risk for days of care or services provided to a beneficiary, but revocation was rarely, if ever, accomplished because the necessary regulations were not promulgated.

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Medicare: A Strategy for Quality Assurance - Volume I 5.   The PRO for Washington State also reviews Alaska and Idaho. The following PROs review in two states: West Virginia for Delaware; Maryland for the District of Columbia; Hawaii for Guam/American Samoa; Indiana for Kentucky; Rhode Island for Maine; Iowa for Nebraska; New Hampshire for Vermont; and Montana for Wyoming. 6.   HCFA put PROs into one of four categories. Two of those categories (28 states in all) were to be awarded full three-year contracts; the remaining categories (26 states and territories) were to be awarded either six or twelve-month extensions of their existing two-year contracts. As of summer 1989, four PRO contracts had not been awarded. 7.   The 11 conditions are cholecystectomy, major joint replacement, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, laminectomy, complex peripheral revascularization, hysterectomy, bunionectomy, inguinal hernia repair, prostatectomy, and pacemaker insertion. A PRO can also select a procedure not on this list if it can document why it should be subjected to 100 percent pre-admission review in the state. 8.   Comments to study site visitors from PRO officials indicated that many Severity Level I cases ultimately turn out not to be quality problems as defined, because they are related to poor documentation. The “quality problem” is not confirmed when the target physician or provider provides sufficient additional information. 9.   HCFA prescribes the format and wording of these letters (apart from the specifics of the case at hand). Presumably for legal reasons, they are very formal in tone and must contain the following information: (1) the Medicare obligations involved; (2) description of the activity resulting in the violation; (3) the authority and responsibility of the PRO to report violations of obligations; (4) a suggested method and time period for correcting the problem (at the discretion of the PRO); (5) an invitation to submit additional information or discuss the problem with the PRO within 20 days of the notice; and (6) a summary of the information used by the PRO in reaching a determination. 10.   As part of a case involving the American Medical Association (AMA) (A.M.A. v. Bowen) settled three years ago, the OIG committed itself to seek a regulatory alternative to the practice of newspaper notices, one that would permit sanctioned physicians to inform their Medicare patients personally that Medicare would no longer pay for the physicians’ services. The OIG drafted a proposed regulation that would require a physician to notify all his or her patients, not just those covered by Medicare. No regulations had been issued, however, as of mid-1989. 11.   The preamble to certain PRO regulations notes that quality problems that affect Medicare patients usually affect all patients, particularly in the context of acute care. Consistently throughout this study, respondents at site visits confirmed this observation. Especially in hospitals and prepaid systems, our respondents noted that most quality problems tended to be with “systems” that cut across units and patient age groups. Moreover, facilities and groups with well-established internal quality assurance systems deliberately did not single out “the elderly” or “Medicare patients” for specific quality assurance attention (except insofar as they needed to meet PRO demands for records and similar requirements), believing that a more efficient and ultimately more successful approach

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Medicare: A Strategy for Quality Assurance - Volume I     to quality improvement would involve the entire institution, its entire staff, and its entire patient census. 12.   Regulations classify “confidential information” as follows: (a) information that explicitly or implicitly identifies an individual patient, practitioner, or reviewer; (b) sanction reports and recommendations; (c) quality review studies that identify patients, practitioners, or institutions; and/or (d) PRO deliberations. “Implicitly identifies” means that the data are sufficiently unique or the numbers so small that identification of an individual patient, practitioner, or reviewer would be easy. 13.   Because PRO budgets are tightly tied to the number of expected reviews, their individual budgets range vary widely. For instance, of the PROs awarded full three-year contracts for the third SOW, the California PRO was awarded nearly $82,838,000—the largest in the country and a record for the PRO program (Vibbert, 1989a)—and the PRO for Wyoming was awarded $1,210,000. Other PROs were awarded extensions of existing contracts for six or 12 months. Of these, the largest award, for 12 months, was to Texas (just over $16.1 million) and the smallest award, also for 12 months, was to American Samoa and Guam ($24,120) (HCFA, unpublished data made available to the study, April 1989). 14.   Material for this section is based in part on a paper prepared for this study, “PRO Review of Medicare Health Maintenance Organizations and Competitive Medical Plans,” by Margaret E.O’Kane, Director of Quality Assurance, Group Health Association, Washington, D.C., May 1989 (O’Kane, 1989). The history of PRO review efforts for HMOs and CMPs is recounted in more detail in Volume II, Chapter 8. 15.   As of December 1989, Quality Quest is the QRO only for Missouri. The Illinois PRO (Crescent Counties Medical Foundation) is the QRO for Illinois. The QRO contract for Kansas had not yet been awarded. 16.   HCFA defined de novo a set of “areas of focus” by which HMO/CMP internal programs would be evaluated, rather than using existing models developed by the National Committee on Quality Assurance (an HMO industry group), the Joint Commission, and similar groups. The HCFA areas were: whether the plan reviews individual cases of patient care; whether it includes physician review of medical records; whether physicians make final decisions on quality issues; whether review includes all settings; whether the plan uses reasonable sampling methods to select cases for review; and whether the plan has been operating long enough for it to be able to demonstrate actual performance. The industry widely regarded these as rather old-fashioned and lacking in an understanding of what HMO and CMP QA plans actually do. 17.   For plans on limited review, the total number of cases selected for the random validation subsample plus the total number selected for the remaining reasons for review cannot exceed the number that would have been reviewed under the basic plan. 18.   By contrast, a “simple” case is one in which services being reviewed were provided in only one setting and during only one admission (if inpatient)—for instance, those in the 3-percent inpatient sample. 19.   Volume II, Chapter 6 discusses several PROs’ remedial education efforts. 20.   The 12 PROs involved in the educational component of the project, known as Medical Assessment Program (MAP) pilots, are located in the following states:

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Medicare: A Strategy for Quality Assurance - Volume I     Arizona, Arkansas, Colorado, Connecticut, Illinois, North Carolina, Ohio, Pennsylvania, Texas, Utah, Virginia, and Washington. It is intended that all PROs receive data, technical training in small area analysis methods, and necessary computer software. 21.   Data provided by HCFA reviewer of draft report. Also see GAO (1988a). 22.   Recall that the screens are (1) adequacy of discharge planning; (2) medical stability of patient at discharge; (3) deaths; (4) nosocomial infections; (5) unscheduled return to surgery; and (6) trauma suffered in the hospital. 23.   Take, for instance, the OIG calculations on data from 12 PROs for Screen 1 on adequacy of discharge planning. According to their data, PRO D failed 0.2 percent of 24,382 cases screened and confirmed problems in 100 percent of failures, whereas PRO F failed 0.6 percent of 80,624 cases and confirmed problems in only 40.5 percent. Both, however, detected confirmed problems in 0.2 percent of cases reviewed (see OIG, 1988b). 24.   For instance, the Peer Review Organization of Washington reported during a site visit that some of its specially developed screens identify more failures and/or confirmed problems than do the HCFA screens. 25.   Countering these moves are recommendations from the Commerce Committee of the U.S. House of Representatives to expand the time during which a physician can claim to be willing and able to change poor practice patterns, extend special appeal rights to most physicians (instead of just those in rural areas), and cap the monetary fines at just $2,500 (Vibbert, 1989d). As of mid-1989, the question of whether the PRO sanctioning capability would be strengthened or weakened was still open. 26.   However, the course of one suit (Amer. Hosp. Assn. v. Bowen) seems to have left HCFA with considerable latitude, because the final court of appeals ruling held that the contracting process, issuance of the SOWs, and Manual transmittals were all covered by exceptions to the APA. 27.   The issue of reimbursing hospitals for costs incurred in photocopying medical records has been especially contentious since 1985. A recent court order requires that HCFA reimburse hospitals retroactively for costs incurred in photocopying; the American Hospital Association argues in favor of a reimbursement at a level of $0.12-per-page (Vibbert, 1989f). 28.   Multi-state HMOs visited during this study differed in their views on this issue. At least one felt very strongly that it wished to deal with only a single PRO because it was experiencing considerable, unexplainable variation in review from the different PROs in the different states in which it operated. By contrast, at least one other plan found PRO review sufficiently benign that differences across PROs were either not noticeable or not a problem. REFERENCES AAPSRO (American Association of Professional Standards Review Organizations Task Force). PSRO Impact on Medical Care Services: 1980. Vols. I and II. Report of the 1980 Ad Hoc Task Force on Impact. Potomac, Md.: The Association, 1981.

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Medicare: A Strategy for Quality Assurance - Volume I AMRRC (American Medical Review Research Center). SMAA PRO Pilots are Progressing Well: An Update. AMRRC Update, pp. 1–2, March-July 1989. Blum, J.D., Gertman, P.M., and Rabinow J. PSROs and the Law. Germantown, Md.: Aspen Systems Corporation, 1977. Blumstein, J.F. Inflation and Quality: The Case of PSROs. Pp. 245–295 in Health—The Victim or Cause of Inflation? Zubkoff, M., ed. New York: Prodist (for the Milbank Memorial Fund), 1976. CBO (Congressional Budget Office). The Effect of PSROs on Health Care Costs: Current Findings and Future Evaluations Washington, D.C.: Congress of the United States, Congressional Budget Office, June 1979. CBO. The Impact of PSROs on Health-Care Costs: Update of CBO’s 1979 Evaluation. Washington, D.C.: Congress of the United States, Congressional Budget Office, January 1981. Chassin, M.R. and McCue, S.M. A Randomized Trial of Medical Quality Assurance: Improving Physicians’ Use of Pelvimetry. Journal of the American Medical Association 256:1012–1016, 1986. Cislowski, J.A. The Peer Review Organization Program. Washington, D.C.: Congressional Research Service, U.S. Library of Congress, October 23, 1987. Committee on Ways and Means. Background Material and Data on Programs Within the Jurisdiction of the Committee on Ways and Means. 1989 edition. Committee Print WMCP 101–4, March 15, 1989. Washington, D.C.: Government Printing Office, 1989. Egdahl, R.H. Foundations for Medical Care. New England Journal of Medicine 288:491–498, 1973. Federal Register, Vol. 50, pp. 15364–15389, April 17, 1985. Federal Register, Vol. 54, pp. 1956–1967, January 18, 1989a. Federal Register, Vol. 54, pp. 42722–42734, October 17, 1989b. GAO (General Accounting Office). Problems with Evaluating the Cost Effectiveness of Professional Standards Review Organizations. HRD-79–52. Washington, D.C.: General Accounting Office, July 1979. GAO. Medicare Improving Quality of Care Assessment and Assurance. PEMD-88–10. Washington, D.C.: General Accounting Office, May 1988a. GAO. Medicare PROs Extreme Variation in Organizational Structure and Activities. PEMD-89–7FS. Washington, D.C.: General Accounting Office, November 1988b. Goran, M.J., Roberts, J.S., Kellogg, M.A., et al. The PSRO Hospital Review System. Medical Care 13:1–33 (Supplement), 1975. Harrington, D.C. Ambulatory Medical Care Data: 20 The San Joaquin Foundation Peer Review System. Medical Care 11:185–189 (Supplement), 1973. HCFA (Health Care Financing Administration). Professional Standards Review Organization 1979 Program Evaluation. Health Care Financing Research Report. HCFA Pub. No. 03041. Baltimore, Md.: Department of Health and Human Services, May, 1980. HCFA. 1988–1990 PRO Scope of Work. Baltimore, Md.: Health Care Financing Administration, Department of Health and Human Services, 1988. HCFA. Request for proposal for the SuperPRO contract, Attachment II. Baltimore, Md.: Health Care Financing Administration, Department of Health and Human Services, 1989a.

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Medicare: A Strategy for Quality Assurance - Volume I HCFA. Technical Notes. Peer Review Organization Data Summary dated May 1989. Baltimore, Md.: Office of Peer Review, Health Standards and Quality Bureau, Health Care Financing Administration, 1989b. HCFA. Utilization and Quality Control Peer Review Organizations Second Scope of Work. Executive Data Summary. Report through March 1989. Report dated 7/5/89. Baltimore, Md. Health Care Financing Administration, 1989c. HCFA. Peer Review Organization Data Summary. May 1989 (includes June 1989 data). Baltimore, Md.: Office of Peer Review, Health Standards and Quality Bureau. Health Care Financing Administration, 1989d. Jost, T. Administrative Law Issues Involving the Medicare Utilization and Quality Control Peer Review Organization (PRO) Programs: Analysis and Recommendations. Report to the Administrative Conference of the United States. Washington, D.C.: Administrative Conference, November 8, 1988 (reprinted in Ohio State Law Journal 50(1), 1989). Kane, R.A., Kane, R.L., Kleffel, D., et al. The PSRO and the Nursing Home: Vol. I, An Assessment of PSRO Long-term Care Review. R-2459/1-HCFA. Santa Monica, Calif.: The Rand Corporation, August 1979. Lohr, K.N. Peer Review Organizations: Quality Assurance in Medicare. P-7125. Santa Monica, Calif.: The Rand Corporation, July 1985. Lohr, K.N., Brook, R.H., and Kaufman, M.A. Quality of Care in the New Mexico Medicaid Program (1971–1975): The Effect of the New Mexico Experimental Medical Care Review Organization on the Use of Antibiotics for Common Infectious Diseases. Medical Care 18:1–128 (January Supplement), 1980. Lohr, K.N., Winkler, J.D. and Brook, R.H. Peer Review and Technology Assessment in Medicine. R-2820-OTA. Santa Monica, Calif.: The Rand Corporation, August 1981. McIlrath, S. Receding Tide of Physician Sanctions by Medicare PROs Triggers Debate. AMA News 3:57, April 21, 1989. Morford, T.G., Director, Health Standards and Qualtity Bureau, HCFA. Testimony before the U.S. House of Representatives’ Committee on Government Operations, Subcommittee on Human Resources and Intergovernmental Relations, April 4, 1989a. Morford, T.G. UpDate. Federal Efforts to Improve Peer Review Organizations. Health Affairs 8(2):175–178, Summer 1989b. OIG (Office of Inspector General, Department of Health and Human Services). The Utiliztion and Quality Control Peer Review Organziation (PRO) Program Quality Review Activities. Washington, D.C.: Office of Inspector General, Office of Analysis and Inspections, August 1988a. OIG. The Utilization and Quality Control Peer Review Organization (PRO) Program Sanction Activities. Washington, D.C.: Office of Inspector General, Office of Analysis and Inspections, October 1988b. OIG. The Utilization and Quality Control Peer Review Organization (PRO) Program. An Exploration of Program Effectiveness. Washington, D.C.: Office of Inspector General, Office of Analysis and Inspections, January 1989. O’Kane, M.E. PRO Review of Medicare Health Maintenance Organziations and Competitive Medical Plans. Paper prepared for the Institute of Medicine Study to Design a Strategy for Quality Review and Assurance in Medicare, May 1989.

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Medicare: A Strategy for Quality Assurance - Volume I OTA (Office of Technology Assessment). The Quality of Medical Care: Information for Consumers. OTA-H-386. Washington, D.C.: U.S. Government Printing Office, 1988. PPRC (Physician Payment Review Commission). Annual Report to Congress, 1989. Washington, D.C.: Physician Payment Review Commission, April 1989. ProPAC (Prospective Payment Assessment Commission). Medicare Prospective Payment and the American Health Care System. Report to the Congress. June 1989. Washington, D.C.: Prospective Payment Assessment Commission, 1989. Vibbert, S., ed. Watchdog Criticizes HHS IG Over PRO Monetary Sanctions. Medical Utilization Review 17(7):1, April 4, 1989a. Vibbert, S., ed. PROs Denied 2 Percent of 1986–1988 Medicare Cases. Medical Utilization Review 17(9): 1, May 2, 1989b. Vibbert, S., ed. Regulatory Activity. Legal Panel Backs PRO Reform Package. Medical Utilization Review 17(13):5–6, June 27, 1989c. Vibbert, S., ed. PRO Sanctions Fight Moves to Senate. Medical Utilization Review 17(15):1–2, August 8, 1989d. Vibbert, S., ed. HSQB Softpedals Controversial Pilot. Medical Utilization Review 17(18):3–4, September 21, 1989e. Vibbert, S., ed. Hospitals Gain Class Action Status in Federal Suit over PRO Photocopying. Medical Utilization Review 17(21):1, November 2, 1989f.