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11
Public Accountability and Program Evaluation: The Committee View

Maxwell J. Mehlman

Of the ten major recommendations of the Institute of Medicine (IOM) committee, three are devoted to the issue of public accountability and program evaluation (IOM, 1990). Although several recommendations are broad in scope, somewhat general, and perhaps difficult to achieve, this was an area in which we felt we could make several specific recommendations that would be fairly easy to carry out. This paper discusses our findings and recommendations in this arena.

BACKGROUND

In our deliberations we examined the existing mechanisms for facilitating public accountability and for evaluating the Medicare quality assurance system. We saw that the Peer Review Organizations (PROs) themselves do some of this in the sense that they have a limited reporting function, particularly to facilitate the review by the Health Care Finance Administration (HCFA) of their ability to fulfill their contracts. HCFA itself, of course, performs program evaluation and is to some extent publicly accountable. We learned about the "PROMPTS-2" system and again found that it focuses primarily on whether the individual PROs have fulfilled their contract requirements.

SuperPRO is another evaluative mechanism, and we learned about some of the recent changes that have enhanced the role of SuperPRO, such as HCFA's selecting cases for review itself rather than relying on PRO-selected cases and the more formal role that SuperPRO evaluation is playing in the HCFA evaluation of PRO performance. This also seemed to be focused primarily on whether the PROs were fulfilling their contract obligations with HCFA.



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Medicare: New Directions in Quality Assurance 11 Public Accountability and Program Evaluation: The Committee View Maxwell J. Mehlman Of the ten major recommendations of the Institute of Medicine (IOM) committee, three are devoted to the issue of public accountability and program evaluation (IOM, 1990). Although several recommendations are broad in scope, somewhat general, and perhaps difficult to achieve, this was an area in which we felt we could make several specific recommendations that would be fairly easy to carry out. This paper discusses our findings and recommendations in this arena. BACKGROUND In our deliberations we examined the existing mechanisms for facilitating public accountability and for evaluating the Medicare quality assurance system. We saw that the Peer Review Organizations (PROs) themselves do some of this in the sense that they have a limited reporting function, particularly to facilitate the review by the Health Care Finance Administration (HCFA) of their ability to fulfill their contracts. HCFA itself, of course, performs program evaluation and is to some extent publicly accountable. We learned about the "PROMPTS-2" system and again found that it focuses primarily on whether the individual PROs have fulfilled their contract requirements. SuperPRO is another evaluative mechanism, and we learned about some of the recent changes that have enhanced the role of SuperPRO, such as HCFA's selecting cases for review itself rather than relying on PRO-selected cases and the more formal role that SuperPRO evaluation is playing in the HCFA evaluation of PRO performance. This also seemed to be focused primarily on whether the PROs were fulfilling their contract obligations with HCFA.

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Medicare: New Directions in Quality Assurance The Office of Inspector General (OIG) of the Department of Health and Human Services (DHHS) and the General Accounting Office have done some systemwide evaluations of the quality assurance program, but they focused on fairly specific issues. Potentially or indirectly a number of other entities might play this role—the Office of Management and Budget, the Office of Technology Assessment, the Prospective Payment Assessment Commission (ProPAC), the Physician Payment Review Commission (PPRC), and of course, Congress itself. This area of public accountability and program evaluation is clearly a very diverse and multi-layered system, but one that the members of the committee thought might be improved in several ways. Our study of these entities gave rise to several concerns. First we asked how well suited these entities are to reflect the emphasis on quality that we have recommended. None of these entities really focuses exclusively on quality as distinct from containing the costs of care, which was a major concern during the committee's deliberations. We felt it was important to be able to assess quality independent of cost concerns. This is reflected in the struggle we had over the definition of quality itself. If we are going to make trade-offs between quality and cost, we want to be clear that is what we are doing. This seemed to us to call for an independent, high-level body that focused exclusively on the quality of care delivered to Medicare beneficiaries. Another concern we had with the existing mechanisms for public accountability and evaluation was the lack of a sufficient, ongoing, systematic evaluation of how well the Medicare system was assuring quality of care. The Office of Inspector General's report (OIG, 1989), for example, tells us that 6 percent of Medicare admissions demonstrate or suggest quality deficiencies, but is this good or bad? We do not know. Is it getting better or worse? This would seem to be a simpler inquiry, but again, we do not know. So we saw a need for a continuous evaluation of the quality of care under Medicare and also of Medicare's mechanisms for assuring quality. In addition to evaluating quality, we also perceived the need to report the results of this evaluation to the public and to bodies that are publicly accountable. Here again we found no formal systematic reporting to Congress about how well the program assures quality. We also found only limited effort by the PROs and by the OIG to document and demonstrate their own impact on quality. In some respects this seemed to be a lack of proclaiming the benefit and success of those programs themselves. It was very difficult for the committee to get a clear picture of the extent of quality problems within the Medicare system, or of how those problems had been detected and dealt with by the PROs and by the OIG. We eventually obtained some information on this, but it is only the numerator of the equation—the number of cases that were detected and that were responded to by the system. It tells us nothing about the denominator, what is out there. In addition, it deals only with the subset of poor-quality providers.

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Medicare: New Directions in Quality Assurance It does not address the rest of the quality question—that is, whether quality as a whole has improved or declined. The committee was also concerned about the extent to which HCFA taps into expertise on quality assessment and assurance that might be available outside of the agency and the extent to which the Medicare quality assurance system is in a position to change and grow, or contract, in light of new research findings. To respond to these concerns, we made several recommendations. First, we recommended the establishment of a congressional commission that we call QualPAC, the Quality Program Advisory Commission. We felt that Congress seemed to work very well with the Prospective Payment Assessment Commission and the Physician Payment Review Commission and took those as our models for this recommendation. QualPAC would be established on a par with those other commissions. The purposes would be (1) to provide advice to Congress about how well the Medicare Program to Assure Quality (MPAQ) is doing and how it might do its job better; (2) to stay on top of quality problems systemwide by identifying them and charting their progression; (3) to conduct studies to support policy evaluations and recommendations; (4) to integrate new research on quality assurance into the quality assurance program; and (5) to serve as a sounding board for groups interested in quality assurance. QualPAC should have a staff comparable to the other congressional commissions and be funded by Congress separately from MPAQ. We also recommended the establishment of a National Council on Medicare Quality Assurance. This would be within the executive branch, whereas QualPAC would have reporting responsibility to Congress itself. The purpose of the National Council, somewhat reminiscent of the council for the former Professional Standards Review Organization program, would be to advise the key entities within the executive branch (DHHS, HCFA, and the Health Standards and Quality Bureau in HCFA) on the MPAQ and how well it is doing, and to afford the executive branch access to the expertise and viewpoints of diverse groups involved with Medicare quality assurance, particularly from the research and quality management communities. We also recommended an additional body within the executive branch, a Technical Advisory Panel. It would advise the DHHS how to evaluate the MPAQ program and help to prepare a report to Congress, which we recommended occur at least every two years. These recommendations do not reflect all of the elements in our report that deal with public accountability and evaluation. We also endorsed the recommendations of the Administrative Conference of the United States (Jost, 1988) encouraging the use of formal, publicly accessible rulemaking proceedings in adopting Medicare policies and policy changes and increasing the access of the public to Medicare written materials and documents.

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Medicare: New Directions in Quality Assurance We also recommended the release of appropriate quality information to the public. Many of us believe that this is potentially one of the best methods for assuring public accountability. REFERENCES Institute of Medicine. Medicare: A Strategy for Quality Assurance. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990. (See especially Volume I, Chapter 12 and Volume II, Chapter 8.) Jost, T. Administrative Law Issues Involving the Medicare Utilization and Quality Control Peer Review Organization (PRO) Programs: Analysis and Recommendations. Report to the Administrative Conference of the United States. Washington, D.C.: Administrative Conference, November 8, 1988 (reprinted in Ohio State Law Journal 50(1), 1989). Office of Inspector General. National DRG Validation Study: Quality of Patient Care in Hospitals, OA1-09-88-00870. Washington, D.C.: Office of Inspector General, Office of Analysis and Inspections, July 1989.