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.



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.


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.


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.


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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