Many of the federal health care accountability systems are housed within the Health Care Financing Administration (HCFA), the principal payer for health care. HCFA has two main quality-of-care strategies: (1) As part of its certification activities, it requires fee-for-service providers, HCFA-contracting health maintenance organizations (HMOs), and clinical laboratories to meet Medicare standards; (2) it undertakes quality improvement initiatives in cooperation with its peer review organization (PRO) programs.
On the regulatory front, HCFA is revising its rules to certify Medicare providers in four areas: home health, hospital care, hospice care, and end-stage renal disease, placing more emphasis on clinical performance and patients' experience with care. The proposed home care rule, for example, would require Medicare home health agencies to use a standard system called the Outcomes and Assessment Information Set (OASIS) to measure quality and patient satisfaction with care (Darby, 1998). HMOs contracting with HCFA must now report clinical performance data (i.e., Health Plan Employer Data and Information Set [HEDIS] data) and information on patients' experience and satisfaction with plans (i.e., results from a new Consumer Assessment of Health Plans Survey). HCFA is also implementing the Quality Improvement System for Managed Care to require participating health plans to show improvement in the health care they provide. Minimum service levels for improvement measures such as mammography will be set, along with targets specific to a geographic region. Initially, the focus will be on preventive and acute care services. A similar system is being developed for fee-for-service care (Voelker, 1997).
Relatively few Medicare beneficiaries are enrolled in managed care plans (13 percent as of 1997), and efforts are underway to gather performance information from providers in the FFS environment. Medicare beneficiaries are beginning to have more choices in type of health coverage beyond fee-for-service and HMOs. With the Medicare+Choice program, beneficiaries will be able to select new insurance options including preferred provider organizations (PPOs) and medical savings accounts. Many believe that HCFA will lead the effort to converge on a single set of quality measures applicable across delivery systems (Darby, 1998).
In 1992, HCFA established the Health Care Quality Improvement Program, which promotes partnerships between PROs and hospitals, health plans, and physicians to improve quality. Each state has a PRO that evaluates whether care given to Medicare patients is reasonable, necessary, and provided in the most appropriate setting. Funding for PROs in 1997 was $183 million. HCFA maintains a quality-of-care surveillance system to provide information to PROs about Medicare health care utilization, patterns, and trends to help PROs target their quality improvement activities. Among the indices tracked are rates of radical prostatectomy among men 70 years or older (see examples of PRO activities in Box 6.3). As of 1998, more than 700 quality improvement projects were underway, some of which were national in scope and disease specific. The Cardiovascular Cooperative Project, for example, is a national, data-based effort to improve care for Medicare patients hospitalized for heart attacks (President's Advisory Commission, 1998). PROs appear to have been effective in improving the care of patients with acute myocardial infarction, according to a recent quasi-experimental assessment (Marciniak, 1997).
HCFA is also actively involved in the development of clinical performance measures to assess quality. As part of HCFA's Outcomes Project, for example, it is identifying multiple domains of processes and outcomes of care for breast cancer, collecting and summarizing the ex-