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OCR for page R5
Medicare: A Strategy for Quality Assurance - Volume I Contents     PREFACE   ix     INTRODUCTION TO THE STUDY AND THIS REPORT   xiii     SUMMARY   1 1   HEALTH, HEALTH CARE, AND QUALITY OF CARE   19      Defining Quality of Health Care,   20      Health and Health Care in the United States,   25      Quality of Health Care as a Public Policy Issue,   31      Summary,   37 2   CONCEPTS OF ASSESSING, ASSURING, AND IMPROVING QUALITY   45      Quality Assessment, Quality Assurance, and Quality Improvement,   45      Criteria for Judging an Effective Quality Assurance Program,   49      Quality Assurance Conceptual Models,   52      Traditional and Continuous Improvement Models Compared,   62      Summary,   64 3   THE ELDERLY POPULATION   69      Size and Growth of the Elderly Population,   69      Sociodemographic Characteristics,   71      Economics of Aging,   75      Use of the Health Care System,   79      Health Status,   85      Summary,   91

OCR for page R5
Medicare: A Strategy for Quality Assurance - Volume I 4   THE MEDICARE PROGRAM   96      Structure, Eligibility, and Benefit Coverage of the Medicare Program,   97      Administration and Financing of the Medicare Program,   102      Expenditures of the Medicare Program,   104      The Prospective Payment System (PPS),   108      Quality Assurance in Medicare,   110      Summary,   111     Appendix A The Medicare Catastrophic Coverage Act of 1988,   114     Appendix B The Medicare Decision Support System,   117 5   HOSPITAL CONDITIONS OF PARTICIPATION IN MEDICARE   119      Standards and Conditions,   120      Inspection and Enforcement,   128      Federal Government’s Roles and Responsibilities,   131      Conclusions,   132      Summary,   134 6   FEDERAL QUALITY ASSURANCE PROGRAMS FOR MEDICARE   138      Experimental Medical Care Review Organizations,   139      Professional Standards Review Organizations,   139      Utilization and Quality Control Peer Review Organizations (PROs),   147      Controversial or Problematic Aspects of the PRO Program,   182      Conclusions About the PRO Program,   195      Summary,   199 7   QUALITY PROBLEMS AND THE BURDENS OF HARM   207      Introduction,   207      Evidence of Problems in Technical Quality of Care,   211      Evidence of Overuse,   220      Evidence of Underuse,   225      Summary,   230 8   SETTINGS OF CARE AND PAYMENT SYSTEM ISSUES FOR QUALITY ASSURANCE   238      Settings,   238      Payment Systems,   254      Other Setting and System Factors,   258      Summary,   259

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Medicare: A Strategy for Quality Assurance - Volume I 9   METHODS OF QUALITY ASSESSMENT AND ASSURANCE   265      Introduction,   265      Prevention of Problems,   267      Detection of Problems,   274      Factors that Impede or Enhance the Effectiveness of Quality Interventions to Correct Problems,   289      Summary,   297 10   CRITICAL ATTRIBUTES OF QUALITY-OF-CARE CRITERIA AND STANDARDS   303      Types of Criteria Sets,   304      Effect of the Type and Use of Criteria on Specification of Desirable Attributes,   309      General Attributes of Criteria Sets,   310      Differences Among Key Attributes for Different Criteria Sets,   319      Methods and Strategies for Developing Quality-of-Care Criteria,   323      Other Issues,   325      Summary,   328     Appendix A Criteria-Setting Expert Panel Activity,   334 11   NEEDS FOR FUTURE RESEARCH AND CAPACITY BUILDING   343      Research Needs,   344      Capacity Building,   360      Funding Issues,   363      Summary,   363 12   RECOMMENDATIONS AND A STRATEGY FOR QUALITY REVIEW AND ASSURANCE IN MEDICARE   368      Findings and Conclusions,   369      Recommendations,   375      Organizational and Operational Features of the Medicare Program to Assure Quality,   387      Responsibilities and Tasks of the MPAQ,   394      Responsibilities and Tasks of the MQROs,   400      Implementation Strategy and Phases,   412      Summary,   419     ACKNOWLEDGMENTS   422     INDEX   427

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Medicare: A Strategy for Quality Assurance - Volume I This page intentionally left blank.