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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