no reliable or comprehensive examination of PRO program impact has been undertaken by DHHS. The several careful external examinations by, for instance, the OIG and GAO have tended to focus on specific operational aspects, such as the usefulness of generic screens or structural aspects of PROs. The same assessment can be made of how HCFA evaluates individual PRO performance; existing tools such as PROMPTS-2, although in transition to improved efficiency, have not been especially successful at providing a coordinated approach to evaluation. The OIG in particular has been critical of HCFA’s ability to assess efforts at PRO performance evaluation (OIG, 1989). When combined with the lack of public oversight and accountability, these evaluation issues appear to have high priority for attention and correction.

Issues in HMO and CMP Review

Records and Case Selection

For HMOs and CMPs, cases for inpatient review are selected on the basis of claims submitted to FIs. This approach does not work well because of insufficient reporting of HMO and CMP admissions (because hospitals have no incentive to bill for such admissions). Thus, it produces a very inadequate “universe” of inpatient claims from which to select the relevant samples. Although efforts have been made to force hospitals to prepare and submit these bills to the FIs, HCFA still estimates that only about half are being submitted (O’Kane, 1989). HCFA has designed measures to overcome this inadequate pool of cases that rely on random sampling procedures; because HMOs and CMPs will differ in the proportion of their total hospitalizations subject to this form of random sampling, an additional source of variability has been added to review in the risk-contract segment of the Medicare program.

Obstacles to acquiring medical charts are also considerable. Obtaining hospital charts is not appreciably more difficult for the prepaid group practice sector than for the fee-for-service sector, although both systems contend that low reimbursement of copying costs ($0.049 per page) and lack of reimbursement for administrative costs have been problems.27 For outpatient records, however, the problems can be extreme, when records for one plan must be retrieved from numerous health centers. Although the problem is manageable for most group- and staff-model HMOs and even for group network models, it presents IPA-model HMOs with extraordinarily complex logistics, since large plans of this sort may have hundreds of physicians practicing in individual offices. HCFA has indicated it would support legislation to allow HMOs to be reimbursed for administrative costs of retrieving such records, which should alleviate the problem to some degree.



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