Medicare A Strategy for Quality Assurance, Volume II: Sources and Methods (1990) / Chapter Skim
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8. The Utilization and Quality Control Peer Review Organization Program
8. The Utilization and Quality Control Peer Review Organization Program
Pages 343-438
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From page 343... ...
PRO activities extend well beyond those emphases into many aspects of the Medicare program, including implementation of the Medicare diagnosisrelated groups (DRG) prospective payment system (PPS)
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From page 344... ...
This act provided for the continued funding of PSROs from the Medicare Trust Fund until PRO contracts could be signed. It also extended the deadline for hospitals to sign a contract with a PRO.
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From page 345... ...
; care rendered in skilled nursing facilities (SNFs) ; care rendered by home health agencies (HHAs)
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From page 346... ...
or have at least one physician in every generally recognized specialty in the area available for PRO review (physician-access organizations)
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From page 347... ...
PRO contracts may be terminated by either the PRO or the secretary of DHHS. The secretary may terminate or choose not to renew a PRO contract when officials determine that the PRO has not met or is not meeting its obligations in a satisfactory manner.
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From page 348... ...
For example, the first SOW emphasized controlling inappropriate utilization, whereas the second and third SOWs direct more attention to assuring quality. The second and third SOWs remained fairly similar as a result of efforts to achieve consistency with minimum disruption to ongoing review activities; much of the second SOW remains in the third, but with variations in the size of sarnples.2 All three SOWs are described in the following sections, but the third SOW is described in greater detail because it is the current guide for PRO work.
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From page 349... ...
Identify all cases in the 25-percent sample with care rendered by skilled nursing facilities, home health agencies, or hospital outpatient departments b. Review a 20-percent sample of each hospital's intervening care universe for quality of care (not medical necessity or overuse of services)
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From page 350... ...
Important Message to Medicare Beneficiaries (from hospitals)
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From page 351... ...
reduce avoidable postoperative or other complications. Corrective actions for physicians or hospitals included education and consultation, intensified review, and denial of payment for inappropriate or unnecessary admissions or readmissions.
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From page 352... ...
care between sampled hospital admissions less than 31 days apart Focused DRGs First SOW: Review of DRG numbers 462 and 46B Second SOW: Review of DRG numbers 462, 468, and 088 Third SOW: Review of DRG numbers 462, 468, 385-391 472 and 474 475b . Day and Cost Outliers First SOW: Originally 100 percent; reduced to 50 percent during contact period Second SOW: 50 percent of day and cost outliers Third SOW: 25 percent of day and cost outliers Medicare Code Editor First SOW: 100 percent of 9 diagnoses with code editor rejects Second SOW: Same as first SOW Third SOW: 100 percent of 12 diagnoses with code editor rejectsC Hospital Adjustments First SOW: 100 percent of all cases adjusted to a higher-weighted DRG Second SOW: Same as first SOW Third SOW: Same as second SOW PI and HCFA Regional Office Referrals First SOW: 100 percent review of cases referred by FI or HCFA regional office for determination of medical necessity Second SOW: Same as first SOW Third SOW: Same as second SOW
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From page 353... ...
Ambulatory Surgery First SOW: Not in scope of work Second SOW: Not in scope of work Third SOW: 5-percent random sample of all cases Intensified Review First SOW: Trigger; 2.5 percent or 3 cases reviewed (whichever is greater)
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From page 354... ...
; retrospective review of all sampled cases to assess the appropriateness of the discharge; review of hospitals that were highmortality rate outliers in the first release of HCFA mortality rate data; an emphasis on statistically identifiable adverse outcomes such as premature discharge and death; and development of a community outreach program. Generic Quality Screens Hospital generic quality screens were the most visible addition to the second SOW (see Table 8.3~.
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From page 355... ...
The focus is on inpatient hospital review, but the activities do not differ appreciably for nonhospital practitioners or settings. Required Review Activities for Hospital Inpatient Care The required PRO review activities for all inpatient hospital cases reviewed are (1)
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From page 356... ...
LOHR AND ALLISON J WALKER TABLE 8.3 Generic Quality Screens Hospital inpatient 1.
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From page 357... ...
The third SOW has also added an adequacy-of-care screen to the set of "trauma" screens to cover inappropriate or untimely assessment, intervention, or management resulting in serious or potentially serious complications. As before, these are applied to every case under PRO review for whatever reason.
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From page 358... ...
LOHR AND AI1ISON J WALKER FIGURE 8.1a Overview of the Quality Review Process for Inpatient Hospital, Home Health Agency, and Outpatient Surgery Generic Screensa 1.
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From page 359... ...
, ~ , 10. Severity ~ Eight assigned: Quality intervention process initiated aIncludes inpatient hospital, home health agency, and outpatient surgery generic screens not covered by the process in Figure 8.1a.
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From page 360... ...
Retrospective admission review identifies whether inpatient hospital care was medically necessary and appropriate; it involves reviewing reasons for admission against pre-established criteria devised or adopted by individual PROs and subjective physician review. Admission review in particular is a traditional utilization review effort that can be traced back to PSRO days and beyond.
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From page 361... ...
Other Aspects of Hospital Inpatient Review In addition to the above required review activities, several other hospital inpatient tasks are now either expanded or required. Each PRO will also be required to publish (at least annually)
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From page 362... ...
. Nonhospital Review Review of Skilled Nursing Facility and Home Health Agency Care: Intervening Care PROs have been directed to undertake review in several nonhospital settings.
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From page 363... ...
Plans for these projects are described later. Nonhospital Generic Screens For the third SOW, generic quality screens have been developed to review care rendered in the following settings: (1)
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From page 364... ...
LOHR AND ALL;fSON J WALKER TABLE 8.4 Nonhospital Generic Screen Categories Home Health Agencies 1.
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From page 365... ...
It includes determination of the source of the problem; assignment of "severity levels" and weights to quality problems; establishment of a time frame for completion of the review process; profiling; and quality interventions that are related to severity levels. Determination of the Source of the Problem All initial case reviews are completed by a nurse reviewer.
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From page 366... ...
The levels (with weights in parentheses) and definitions are as follows: Severity Level I (1~: Medical mismanagement without We potential for significant adverse effects on the patients Severity Level II (51: Medical mismanagement with the potential for significant adverse effects on the patient Severity Level III (25~: Medical mismanagement wide significant adverse effects on the patient Time Frames for Quality Review HCFA set a maximum time frame for quality review.
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From page 367... ...
Quality Interventions When a PRO identifies a quality problem resulting from case mismanagement, then the PRO develops a corrective action plan using a variety of interventions. The six types of interventions listed below must be included in its contract review plan, but the PRO may add more.
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From page 368... ...
These scores are computed at least quarterly for each problem source (e.g., physician or hospital) ; they are simply sums of the total points of Severity Levels I, II, and III given earlier.
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From page 369... ...
. If the concern is not resolved, the procedures at this point follow the pattern for gross and flagrant violations.
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From page 370... ...
_ _ Provider has 20 days to submit additional information and/or request a meeting i- ~ Not a substantial violation PRO decides that a substantial violation has occurred ~ Provider complies with corrective plan and develops a corrective plan of action within specified time period Provider does not comply with corrective plan r - - - J - - - _ I I Second sanction notice ! | PRO decision l _ _ _ _ _ _ I Final sanction notice; PRO recommendation on I I decision to Office of the Inspector General of HHS I | HHS Office of the Inspector General decision | ~ Do not sanction Provider appeals sanction to an administrative law judge of HHS HHS Administrative Law Judge decision Provider has 30 days to submit additional information andJor request a meeting Not a substantial violation Provider has 30 days to submit additional information to Office of the Inspector General Provider accepts sanction Dismiss sanction Sustain (or modify)
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From page 371... ...
sanction - -- -- - ~ Provider accepts sanction Provider appeals sanction to the HHS Appeals Council r - Secretary of HHS Appeals Council decision -- -r -- - _ I Sustain (or modify) sanction Provider seeks judicial review of HHS Appeals Council's decision to sustain sanction Court de_ _ Sustain sanction in- ~ Dismiss sanction Provider accepts sanction Dismiss sanction aA flagrant violation is a violation that has occurred in one or more instances and presents an imminent danger to the health, safety, or well-being of a Medicare beneficiary.
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From page 372... ...
By contrast, intensified review, formal education or similar programs, and sanction recommendations are used much less often, although during the second SOW more than 53 percent of hospitals were under intensified review for at least 1 quarter (HCFA, 1989c)
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From page 373... ...
TABLE 8.5b Quality Intervention Activities of PROs Through February 1989: Quality Interventions for Physicians Category Number of Cases Newly Identified Repeat cases Physicians with quality problems Physicians with quality problems resolved Quality interventions taken 87,075 81,440 70,321 20,598 19,888 26,871 SOURCE: HCFA, 1989c. TABLE 8.5c Quality Intervention Activities of PROs Through June 1989: Sanctions Category of Activity Number of Physicians Providers First notices sent Substantial violations Gross and flagrant violations Second notices senta Cases referred to the Office of Inspector General Substantial violations Gross and flagrant violations 907 335 572 68 109 29 80 9 158 109 49 17 10 1 aSecond notices are sent only in cases of substantial violations.
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From page 374... ...
Other PRO Required Activities Beneficiary Relations The PROs are required to act on behalf of Medicare beneficiaries in four ways not directly related to the technical quality of care rendered by providers or physicians. They must monitor hospital distribution of An Important Message from Medicare (concerning patients' rights to appeal denials of hospital care)
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From page 375... ...
When the attending physician disagrees with the hospital's desire to issue a notice of noncoverage and the hospital requests PRO review, the hospital must notify the beneficiary, in writing, that it has made that request. Before the PRO makes its review determination, it must make every effort to solicit the views of the patient, the physician, and the hospital.
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From page 376... ...
PROs must conduct programs to inform beneficiaries about Medicare PRO review and PPS; more specifically about the purpose of PROs and PPS, types of PRO review, and their right to appeal a PRO determination. PRO s are also expected to devise ways to explain how they ensure the quality of care and respond to complaints from beneficiaries.
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From page 377... ...
In general, the outreach activities envisioned for providers are similar to those required for beneficiaries (seminars, informational material, etc.~. Data Acquisition, Sharing, and Reporting PROs are required to exchange information with FIs and carriers, with other PROs, and with other public or private review organizations.
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From page 378... ...
HCFA regulations distinguish between confidentially and nonconfidential information. They also limit the release of patient-identifying and physician-identifying information to that required for PRO review or for other statutorily required reasons.
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From page 379... ...
and by not including the corrective action information. Finally, as noted above, PROs are expected to obtain information on disciplined physiciansfrom various state authorities, but their responsibility to provide information on physicians who are involved in quality interventions (corrective action plans)
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From page 380... ...
at approximately $300 million a year, up from $157 million a year for the first round of PRO contracts (FY 1984-1986) and $217 million a year for the second round of PRO contracts (FY 198~1988~.
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From page 381... ...
Still, even if the $11 million intended for pilot projects were added to the estimates given above for the PRO program, its expenditures would not exceed those of the PSRO program as a percentage of expected Medicare outlays. Given the expanded responsibilities of the PROs compared with the PSROs, the markedly changing environment of health care for the elderly, and the greater perception of threats to high-quality care in the future, some view this level of funding as parsimonious.
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From page 382... ...
, and $9.16 for ambulatory review (range, $4 to almost $151. QUALITY REVIEW IN MEDICARE RISK-CONTRACT PLANS17 As of April 1989, 1 million Medicare beneficiaries were enrolled in 133 "risk contracts" held by HMOs and CMPs.
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From page 383... ...
The final TEFRA regulations, which became effective February 1985, included provisions requiring risk-contract HMOs and CMPs to comply with requirements for PRO review. In short, before COBRA, no specific legislative requirements existed for the review of services provided to Medicare beneficiaries enrolled in riskcontract HMO s and CMPs, but review was nonetheless contemplated by HCFA.
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From page 384... ...
OBRA 1986 allowed review of HMO and CMP services by entities other than PROs in the area as a means of stimulating competition among review organizations. These other entities are referred to as Quality Review Organizations (QROs)
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From page 385... ...
Basic review is the core approach to HMO review. Limited review is intended to reduce the volume of active TABLE 8.6 Summary of Activities for Health Maintenance Organization (HMO)
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From page 386... ...
If a pattern of problems (relating to Outcomes 1 and 4 above) becomes apparent, the PRO then monitors the plan's corrective actions and may assign the HMO to intensified review.
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From page 387... ...
The Review Process By and large, the process for reviewing care rendered to Medicare beneficiaries in risk-contract HMOs and CMPs is similar to the process for reviewing care in traditional FFS settings (e.g., use of generic screens, assignment of severity levels, physician or plan notification, and the like)
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From page 388... ...
Known as the Uniform Clinical Data Set (UCDS) , this project is one of a number of steps intended to expand and improve the ability of the agency to assure the quality of care delivered to Medicare beneficiaries, using the PROs as the principal mechanism.
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From page 389... ...
Nurse reviewers who flag instances of potential quality deficiencies for more in-depth review will have more organized, objective, clinical information before them, and physician reviewers likewise will have better organized information on which to base their decisions. More broadly, HCFA hopes to be able to set national and individual PRO goals for improving quality of care and to measure the success of PROs in reaching those goals (Morford, 1989a, 1989b)
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From page 390... ...
LOHR AND ALLISON J WAVER TABLE 8.7 Elements of the Uniform Clinical Data Set I
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From page 391... ...
Current neonatal exam findings (e.g., gestational age; Apgar)
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From page 392... ...
return to operating room VII. Treatment Interventions (This section covers various data items relating to noninvasive procedures.)
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From page 393... ...
SOURCE: "Resource Manual for Uniform Clinical Data Set (U.C.D.S.) ," pre pared by Case Mix Research, Queen's University, Department of Community Health and Epidemiology, Kingston, Ontario, Canada, in association with the Wisconsin Peer Review Organization (WIPRO)
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From page 394... ...
An assessment and recommendation about whether to go forward with this approach as an integral part of the PRO quality review task is expected late in 1990. Pilot Projects for PROs Apart from the UCDS activity, HCFA and the PRO community are embarking on a series of pilot projects designed to begin the implementation of several new review activities required by legislation (e.g., OBRA 1987~.
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From page 395... ...
systolic; diastolic SOURCE: "Resource Manual for Uniform Clinical Data Set (U.C.D.S.) ," prepared by Case Mix Research, Queen's University, Department of Community Health and Epidemiology, Kingston, Ontario, Canada, in association with the Wisconsin Peer Review Organization (WIPRO)
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From page 396... ...
Organ System Algorithms Cardiac system Vascular system Pulmonary system Gastrointestinal system Genitourinary system Bone, joint, and muscular system Neurological system Infectious diseases Endocrine system IV. Generic Quality Screen Algorithms Adequacy of discharge planning Medical stability of patient at discharge Deaths Nosocomial infection Unscheduled return to surgery Trauma suffered in hospital V
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From page 397... ...
The first is a statistical assessment of the "impact of the physician's services on the condition of his overall patient population"; the second is an evaluation of cases with unexpectedly adverse risk-adjusted outcomes. Reduced Hospital Review The first pilot projects in this category were intended to develop alternative mechanisms by which hospitals can be put on "reduced review"; that is, be "focused out" of the level of review they presently experience.
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From page 398... ...
Other Activities Small Area Variations. Perhaps the most ambitious PRO project currently under way is a small area analysis of variation in utilization and outcomes of hospital care being conducted by the American Medical Review Research Center (AMRRC)
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From page 399... ...
EVALUATING PRO ACTIVITIES HCFA has three mechanisms to monitor and validate PRO medical review activities: (1) the PRO Monitoring and Protocol Tracking System (PROMPTS-2~; (2)
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From page 400... ...
Thus, the focus is more on "process" aspects of performance than on "outcomes," and more on contract deliverables and cost-containment efforts than on quality of care. The 400 points to be assigned to four categories of PRO activity (utilization review, quality review, data, and management)
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From page 401... ...
, SuperPRO received 400 hospital medical records randomly selected by each PRO from among the cases it reviewed during that cycle. SuperPRO used the same generic screens initially applied by the PRO to judge each case.
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From page 402... ...
For instance, for Cycle 6 of SuperPRO review (dated mid-December 1988) , PROs collectively had a denial rate (based on lack of medical necessity)
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From page 403... ...
will select the random sample of cases, now to number 600 per 6-month cycle (217 inpatient admissions, 195 HMO cases, and 188 ambulatory surgery cases)
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From page 404... ...
educational activities and successful quality interventions. A sixth part of the survey focused on desirable improvements to the PRO review program.
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From page 405... ...
PROF 3, Completed Review Record, collects the completed results of all cases reviewed either prepayment or retrospectively. PROF 4, Ambulatory Surgery Record, reports data on ambulatory surgery performed in HOPDs and ASCs, and it will reflect review of the required S-percent random sample.
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From page 406... ...
Profiles of other provider statistics, for example: Home health agencies, skilled nursing facilities, ambulatory surgical centers D Profiles for internal quality control: Review determination denials, DRG validation findings, arid audit Review decisions by: Physician reviewers Review coordinators SOURCE: HCFA, 198B.
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From page 407... ...
An adjustment report is also produced monthly to monitor the number of adjustments in data generated, forwarded, pending, and returned to the FI. Medical Review Activities Medical review activities generate four types of management information reports, which are produced on a monthly basis.
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From page 408... ...
Finally, internal quality control reports, produced quarterly, concern information about the accuracy of decisions made by nurse reviewers and physician advisors that would enable PROs to identify problems in management. CONTROVERSIAL OR PROBLEMATIC ASPECTS OF PRO QUALITY-RELATED ACTIVITIES Issues Relating to PRO Activities in All Systems or Settings Generic Screens The initial experience with inpatient generic screens has come under considerable scrutiny and criticism.
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From page 409... ...
The most productive screens relate to adequacy of discharge planning and nosocomial infections. Another question sometimes raised about generic screens is related to the fact that they are applied to cases targeted for review for many reasons.
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From page 410... ...
, by Type of Screen Range of Generic Screen Screen Failures Confirmed Problems Adequacy of discharge planning 0.2-19.1 2.1-lOO.Oa Medical stability of patient at discharge 1.4-38.6 0.1-68.5 Deaths 0.~5.8 0.0-37.1 Nosocomial infections 1.1-20.4 0.4_95.7b Unscheduled return to surgery 0.2-2.6 0.0-66.7 Trauma suffered in hospital 1.0-24.1 2.2-65.8 aFour Peer Review Organizations (PROs) reported numbers that yielded a figure above 100%, the highest one squalling 109.1%.
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From page 411... ...
ProPAC TABLE 8.13 Percentages of Cases Failing Generic Screens and with Confirmed Problems, by Generic Screen and Universe of Cases Percent Percent Percent Confirmed Failing Confirmed Problems Generic Screen Screen Problems Among and Universe of Cases Review Among Failures Reviewed Cases All casesa Adequacy of discharge planning 3.05 71.27 2.18 Medical stability of patient 12.47 10.60 1.32 at discharge Deaths 1.49 7.50 0.11 Nosocomial infections 7.84 35.67 2.80 Unscheduled return to surgery 0.99 7.56 0.08 Trauma suffered in hospital 4.92 20.82 1.03 Cases in the 3-percent samples Adequacy of discharge planning 2.93 79.52 2.33 Medical stability of patient 12.87 10.76 1.39 at discharge Deaths 1.24 8.45 0.11 Nosocomial infections 6.53 31.84 2.08 Unscheduled return to surgery 0.62 7.07 0.04 Trauma suffered in hospital 4.05 21.46 0.87 aNumber of all cases reviewed: 6,309,839. bNumber of cases reviewed in 3-percent sample: 705,983.
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From page 412... ...
(This may have been more true in the first and second SOWs than the third, because as of now HCFA will pay for reviews conducted for these reasons.) Furthermore, PROs will differ in the collection of cases to which they apply generic screens because they will have hospitals and physicians on 100-percent intensified review for different reasons and problems and because they will have different mixes of hospital transfers to other types of units.30 Finally, some cases are targeted for review precisely because a quality problem is considered more likely (e.g., day or cost outliers; the first of a pair of admissions within 31 days; and most cases on intensified review)
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From page 413... ...
If, however, the quality assurance program were to remain more responsive to "local" needs and circumstances, then flexibility and local autonomy about these elements of the review process are both more important and more acceptable. Whether generic screens are a strong and reliable tool on which to base a considerable part of the Medicare quality assurance effort seems problematic, and a rigorous evaluation of their utility and productivity is probably warranted.
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From page 414... ...
Fls do the same set of tasks, as well as limited quality review, for inpatient hospital care, outpatient hospital care, SNF and HHA care, hospice care, outpatient rehabilitation facility care, and Part B outpatient physician therapy. PROs, of course, do utilization review, quality review, verify bill and DRG data, and initiate sanctions for substandard care for inpatient hospital care, TEFRA HMOs and CMPs, ASCs, and "intervening" EIHA and SNF care, with their role regarding physicians' services in office settings to be determined (PPRC, 1989, p.
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From page 415... ...
, specialists not being reviewed by members of their own specialty, and physicians for whom the relatively low reimbursements for PRO review are an important portion of their income. Physicians in prepaid group practice settings reviewed by those in FFS settings are discussed later.
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From page 416... ...
Others argue that PROs lack legal expertise, which has led to inadequate protection for the due process rights of sanction targets. Thus, one proposal is to turn the sanction function over entirely to the OIG.32 PROs would continue their quality assurance functions by monitoring medical records, investigating complaints, and requiring corrective action where quality problems were identified;-they could put into effect other interventions that they currently use, such as limiting practice, mandatory consultation, preceptorships, attendance in residency programs, obtaining board certification, and requiring oversight in surgery (Jost, 1989~.
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From page 417... ...
Correcting some of the other problems of the entire sanctioning process, however, does appear to offer ways to strengthen the government's ability to protect the quality of care delivered to Medicare beneficiaries. Monetary penalties.
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From page 418... ...
Among other etchings, it effectively required that PROs demonstrate that a doctor or institution was unable to conform to a corrective action plan, because the physician or institution can claim that it was both able and willing to meet the specified obligations or corrective action. Thus, although the "unable and unwilling" provision can be seen as a desirable aspect of due process for physicians or institutions, it is a nearly impossible task and one that can take a very long period of time (during which the practitioner or provider could continue to provide services)
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From page 419... ...
, but because of their legalistic and punitive tone' these are not universally liked in the PRO community.34 Denials for Substandard Quality of Care COBRA and OBRA 1987 allow PROs to deny Medicare payment for substandard quality of care, although the provisions of the legislation were not implemented awaiting final regulations; a draft proposed rule to effect these requirements was published in January 1989 (Federal Register, 19891. It required payment to be denied when substandard care resulted in actual, significant adverse effects on the beneficiary or placed the beneficiary in imminent danger of health, safety, or well-being (i.e., places the beneficiary in a situation that constitutes a "gross and flagrant violation"~.
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From page 420... ...
The proposed rule further provided that hospitals would be held financially liable even if they did not contribute directly to the substandard care rendered by the physician. Thus, any denial of physician payment on these grounds would also result in a denial of reimbursement to the hospital.
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From page 421... ...
Specifically, it provided that the PRO should not notify beneficiaries until after the PRO had notified practitioners or providers of its determination about the quality problem and their right to a reconsideration; if the practitioner or provider requests such a reconsideration, then one would be conducted before any notices to beneficiaries. Second, it softened the wording of the beneficiary notice, by saying that the letter need only state: "In the judgment of the peer review organization, the medical care received was not acceptable under the Medicare program.
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From page 422... ...
6) , should publish SOW rules in the Federal Register with 30 to 45 days for public comment, and should publish PRO contracts, Manual instructions, and other guidelines quarterly in the Federal Register (Vibbert, l989c)
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From page 423... ...
Virtually no reliable or comprehensive examination of PRO program impact has been done within DHHS. The several careful external investigations by the GIG and GAO have tended to focus on specific operational aspects (e.g., usefulness of generic screens; structural aspects of PROs)
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From page 424... ...
The statute limits the number of staff to 26, and the annual budget for the ProPAC activities approaches $4 million. Physician payment under Medicare has come under close scrutiny in the last several years, and Congress established PPRC in 1986 to advise on reforms to the physician payment system under the Medicare program (PPRC, 1988, 1989~.
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From page 425... ...
To meet this objection from the HMO industry, the HMO-C SOW requires the PRO to use HMO-CMP physicians to perform reviews whenever possible. In addition, conflicts of interest can arise in several instances: when only FFS physicians review HMO-CMP care, when HMOCMP physicians review care rendered by a plan from which they may receive financial benefit, and when HMO-CMP physicians review care from a competing plan.
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From page 426... ...
Second, PROs are expected to review all care rendered in a case that falls into the limited review sample,
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From page 427... ...
Finally, because of the second factor (the scope of PRO review versus that of HMO review under its own quality assurance program) , the HMO under limited review in theory can run more of a risk than the HMO under basic review of being subjected to intensified review on the basis of PRO findings on the "validation subsample" (i.e., cases having been reviewed by the HMO pursuant to its own quality assurance plan)
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From page 428... ...
By contrast, at least one other plan found PRO review sufficiently nontroublesome that differences across PROs were either not noticeable or not a problem. The question of valid comparisons is especially problematic for those states with only a single risk contractor, because information about numbers of cases reviewed and numbers and percentages of quality problems cannot be protected from public disclosure.
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From page 429... ...
. Among the issues discussed are the following: the usefulness of hospital generic screens, the practical question of ensuring review by peers, the limitations of the current sanctioning process and denials for substandard care, the adequacy of public oversight and adminis~aiive procedures for the program, and the lack of any systematic program evaluation to date.
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From page 430... ...
6. Interpretative guidelines for generic screens include two features, exclusions and explanatory notes.
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From page 431... ...
15. Regulations define "confidential information" as information that explicitly or implicitly identifies an individual patient, practitioner, or reviewer; sanction reports and recommendations; quality review studies that identify patients, practitioners, or institutions; and/or PRO deliberations.
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From page 432... ...
17. Material for the Medicare risk-contract section is based in part on a paper prepared for this study, "PRO Review of Medicare Health Maintenance Organizations and Competitive Medical Plans," by Margaret E
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From page 433... ...
28. Figures cited in the text concerning the rates of quality problems found by the SuperPRO are from the oral testimony of Christy Moynihan, Ph.D., of SysteMetrics, Inc., at the October 21, 1988, public hearing of the IOM Study to Design a Strategy for Quality Review and Assurance in the Medicare Program.
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From page 434... ...
are the two screens for which nurse reviewers need not refer cases to physician advisors.
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From page 435... ...
Dans, P.E., Weiner, J.P., and Otter, S.E. Peer Review Organizations: Promises and Pitfalls.
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From page 436... ...
Program. Quality Review Activities.
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From page 437... ...
O'Kane, M.E. PRO Review of Medicare Health Maintenance Organizations and Competitive Medical Plans.
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Key Terms
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