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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
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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.