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.