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Medicare: New Directions in Quality Assurance 24 A Peer Review Organization Response to the Institute of Medicine Report William H. Moncrief, Jr. The Institute of Medicine (IOM, 1990) report is—I will not say it is the greatest thing since sliced bread—but I think it has affected the Medicare Peer Review Organization (PRO) program positively. In addition to the IOM report, one of the good things to happen to the PRO program has been Thomas Morford for his consistent and positive support and direction for the program (see Morford, 1991). This is the same way that the PRO community looks at the IOM report. It leads us in a positive direction and focuses renewed attention on the quality-related issues that are within the Medicare program. As is mentioned in several papers, there are quality issues in the delivery of care to the Medicare beneficiary. I would like to emphasize quality issues because in the PRO lexicon a quality issue is a perception by the PRO that there is a problem with the care that the beneficiary has received, but it is not a quality problem until we have discussed the issue(s) with the practitioner or with the provider. So when I say that there are quality issues in the Medicare program, I think these are based on the data that we have and the review that we do. One of the interesting things is that as the Medicare program goes, so goes the private sector. I see the IOM report as setting a course of action that will assure quality of care for all consumers, not only the Medicare population. NEW DIRECTIONS SUPPORTED BY THE PRO COMMUNITY The definition of quality of care is excellent and well reasoned; it includes not only the individual but also the community of patients, the community of consumers. Certainly any quality assurance program must be able to assess the impact of a medical intervention on patient health status.
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Medicare: New Directions in Quality Assurance The PRO community strongly supports the call for the development of a comprehensive patient outcome data base. Historically, as Morford (1991) mentions, the PRO data base has been fragmented and incomplete, and the changes in the focus of the review have further fragmented the PRO data base. This has not permitted the PRO community to come up with any concept of outcomes, nor has it allowed for the development of an efficient or effective patient care review methodology across the continuum of care. Historically the PRO community has been extremely uneasy with looking at a snapshot of care as we have for the last several years. The emphasis in the IOM report on the continuum of care is to be applauded. In the Third Scope of Work the PRO community is beginning to look outside the acute hospital environment. As it develops expertise in the non-acute hospital review, the PRO community could make a definite contribution to the data accumulating on non-acute hospital care. The PRO community likewise applauds the shift from focusing on the single event, and on the outlier, to looking at patterns of care. In looking at patterns of care the PRO can focus on institutions, hospital administrations, and hospital medical staffs as deliverers of care, rather than focusing on the single practitioner. The PRO community certainly agrees that an internal institutionally based quality assurance program must be encouraged and that, at a minimum, good performers should be rewarded with less review. Particularly in the Third Scope of Work the PRO program clearly identifies the problems in the acute hospital environment; problems will be assigned to the hospital, as well as to the practitioner, no matter the source. This is an effort in the PRO program to look at institutionally based delivery of care and to look at patterns of care rather than focusing on the practitioner or the ''bad apple.'' The development of a comprehensive Medicare outcome data base is not going to come easy. I am pleased to hear, according to Morford (1991), that we will be able to implement the Uniform Clinical Data Set in the near future. However, I think we have to be very careful about using data alone to make judgments about practitioner and provider performance. The American Medical Peer Review Association (AMPRA) believes that, both in the transition period when the data base is being developed and in the long term when the data base is operational, local physician peer review of medical records must continue to play a significant role in the program's ability to validate outcomes and to make final determinations about practitioner and provider performance. Moreover, as Morford (1991) mentions, the PROs have a statutory obligation to take appropriate action in individual cases of unnecessary and poor quality care. The PROs will greatly appreciate a broad data base because it will help them target their review of suspected deficiencies and should lead to a more efficient and effective external monitoring system that is less intrusive on the provider community.
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Medicare: New Directions in Quality Assurance CONTINUING NEED FOR RECORD REVIEW The PRO community is concerned about the perception among the media and in some portions of organized medicine that, by emphasizing use of a data base to focus on providers and practitioners, individual case record analysis will be abandoned. We are going to have to continue to review individual case records. The PRO community recognizes its lack of expertise in statistical analysis—that is, the in-house, biostatistical, epidemiological, and other expertise that is required to evaluate the data that the PRO community is accumulating. Thus, we would encourage the capacity building and, indeed, would endorse it enthusiastically. Historically in the PRO community, practitioner involvement has been almost a pro bono effort. It is very difficult to get the cardiovascular surgeon, the invasive cardiologist, or the neurosurgeon to take a course in epidemiology, health statistics, or similar studies so that he or she can make a better, more scientific contribution to analysis of the PRO data. As we move into this capacity building effort, we hope we will be able to build on those practitioners who are involved in the PRO program and retain them in the PRO program. The PRO community is finding that as we develop practitioners who are skilled in analysis we are losing them to the private sector. We cannot retain them, just as we cannot retain the good review nurses. This is a major problem. AMPRA and the PRO community are not wedded to the QualPAC and the Council concept.1 We have endorsed and have encouraged and are on record as saying that HCFA and its Health Standards and Quality Bureau (HSQB) should have readily available to them outside advice and counsel on management of the PRO program. I think that HSQB does take advantage of this. Sometimes I wonder if the expertise that HSQB calls on is quite as constructively critical of the PRO program as it should be. I think that HCFA and HSQB would benefit from outside expertise, and we recommend that a mechanism be found to ensure consistent and frequent input. The PRO community does not agree with the total IOM report. Although AMPRA supports the self-monitoring and internal organizational improvement, the report also suggests that external regulation and inspection of the type characterized by the existing PRO program is incompatible with or a hindrance to such a goal. The PRO community strongly disagrees with this portion of the report. On the contrary, AMPRA believes that the primary 1 Editors' Note: The reference is to the IOM recommendation concerning the establishment of an independent expert advisory body for Congress (the Quality Program Advisory Commission or QualPAC) and for the Department of Health and Human Services (the National Council for Medicare Quality Assurance).
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Medicare: New Directions in Quality Assurance impact of the PRO program to date has been to encourage institutions to develop good quality assurance programs. As the PROs implement the Third Scope of Work where providers (hospitals) are assigned quality problems, no matter the source, we will see further movement in this direction. One of the problems with institutions developing an effective, efficient quality assurance program has been that such programs are resource intensive. The PRO program currently is designed to feed back identified quality concerns to hospitals and direct the institution to take corrective action. We feel that the PRO program is an important stimulant rather than an obstacle to fostering professional self-monitoring and internal organizational movement to this end. One other issue remains. The study suggests in several points that consideration be given to transferring PRO utilization review activities to other HCFA contractors. AMPRA does not support this idea. We believe that issues of quality and utilization are inextricably linked. Utilization management is very much a quality issue. We also believe that considerable efficiencies are possible when a single entity reviews care for both medical necessity and medical quality. SUMMARY In summary, AMPRA believes that establishing a long-term strategy for Medicare quality assurance is a policy imperative, one that all parties must now work together to achieve. The IOM study has made a valuable contribution to designing a framework and setting a direction for the future. The challenge, as AMPRA sees it and as the study concludes, is not to start over but to strike an appropriate balance between adding new tasks and responsibilities and retaining the best features of the current system. REFERENCES Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990. Morford, T. An Administration Response to the Institute of Medicine Report from the Health Care Financing Administration. Pp. 179-185 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.
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