Medicare A Strategy for Quality Assurance, Volume II: Sources and Methods (1990) / Chapter Skim
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2. Oral and Written Testimony from the Public Hearings
2. Oral and Written Testimony from the Public Hearings
Pages 7-34
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This chapter describes the public hearing process used for this study and summarizes the main themes raised by the written submissions. METHODS Invitations to Submit Testimony The invitahona1 package included a transmittal letter, a set of guidelines for written testimony (see Appendix A)
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By far the greatest number of invitations was sent to professional associations (238~; about one-quarter responded. Respondents to the Invitations We convened two formal public hearings.
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Some took up the majority of key questions but confined their comments to only one area of health care (such as home health care) or to only one particular professional practice (such as critical care nursing, enterostomal therapy, or occupational therapy)
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This chapter makes no attempt to differentiate between these interests. FINDINGS This section summarizes the content of the testimony received through the public hearing process.
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Later sections elaborate on these topics as they relate to the key questions from the guidelines. Gaps in Information The majority of respondents believed that gaps exist in the knowledge base for effective quality assessment and assurance.
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Respondents expressed concern that pressure to contain costs results in pressure to provide lower-quality health care. Some respondents stated that, given the limitations of the Medicare financing structure, the elderly do not receive quality care because they cannot afford to purchase needed health care.
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Some respondents discussed the uniqueness of elderly individuals, the importance of the quality of life, the limitations of the Medicare reimbursement system for a population that experiences chronic illnesses, and the need for tools that measure the health status of an individual beyond the scope of the medical model. Continuous Quality Improvement A few respondents wrote about the effectiveness of the continuous quality improvement model, and some incorporated its concepts in their definitions of quality.
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expressed uneasiness that the quality of health care would decrease as a result of cost containment efforts. Premature discharges, utilization review, financial incentives for underuse, and health care decisions being made by the (alleged)
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Among those respondents who thought that the health care system is not responsive to the unique characteristics of the elderly population, many cited the need for a more humane relationship between the elderly consumer and the provider. Some comments focused on the fragmentation of the health care system, the increase in subspecialty practices, and a decrease in the role of the primary physician.
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Medicare's cost containment emphasis has shifted the power from the physician to employers and businesses who are ill equipped to ask the right kinds of questions about quality. Costs of Quality Assessment and Assurance Activities Very few respondents provided information on the costs of their quality assessment and assurance activities.
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have either major or limited roles in conducting external quality assessment and assurance activities. Other respondents are actively developing tools for assessment and assurance processes; examples included the American College of Physicians through their Clinical Privileges Project and the Nahona1 Association of Boards of Examiners for Nursing Home Administrators through their national examination for nursing home administrators.
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Comments of other groups conducting external quality reviews. The "only way to win" is to use quality improvement as a positive internal driving force rather than relying on the feared weapon of outside evaluators.
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External reviews by the state are too rigid. Private review organizations using claimsbased information are more effective.
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information systems to retrieve and process quality assurance data. External reviewers do not adequately monitor providers, in particular in the Paining requirements for home health aides and Me quality of services provided by the aides, the accessibility to and quality of home medical equipment, and the administering of procedures such as IV therapy and parenteral nutrition.
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Thirty-five respondents, or about 25 percent of all those submitting testimony, judged the level of current activities to be too low. Adequacy of Current Quality Assessment and Assurance Tools or Methods Ninety-five respondents identified particular elements of the quality assessment and assurance system they found inadequate.
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Coordinating Quality Assessment and Assurance Activities The need for more efficient and effective coordination of quality assurance efforts was a concern addressed by about half of the respondents. Many respondents suggested dividing roles and responsibilities among the governmental bodies, the provider facilities, peers of the provider, and patients and consumers.
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The recommendations presented by our respondents are summarized below. They are grouped into five categories relating to health care, broad quality-of-care topics, quality assessment methods, specific quality assurance activities, and research and development.
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c. Establish a national organization to work with professional societies in developing their own quality assurance activities or systems (3~.
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c. Support deemed status for home health agencies (and nursing homes)
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a. Evaluate current quality assurance programs including both the PRO program and other efforts (12~.
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APPENDIX A GUIDELINES FOR WRITTEN TESTIMONY A SI-UDY TO DESIGN A STRATEGY FOR QUALITY REVIEW ED ASSURANCE IN MEDICARE PART A BACKGROUND The IOM Study Committee is interested in a broad set of issues relating to the quality of health care delivered in all major settings in which the elderly receive care, for instance, hospitals, free-standing clinics, physicians' offices, and health maintenance organizations.
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. different perspectives and definitions of quality of care; the current levels of quality of health care; potential or emerging problems with quality of care; current or future methods to use in assessing quality of care; organizations that now engage in various quality assurance activities; possible strategies for assuring the quality of health care; leadership and coordination of quality assurance programs; and needs for further research.
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(c) What do you estimate is the cost of your assessment and assurance activities-for instance, dollars spent per case reviewed, or percentage of your total annual budget spent on quality-related activities?
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Address for mailing testimony: Telephone contact Quality Assurance in Medicare Study for assistance: Institute of Medicine Jo Harris-Wehling Molla S Donaldson 202/334-2165 National Academy of Sciences 2101 Constitution Avenue, NW Washington, DC 20418 APPENDIX B ORGANIZATIONS SUBMITTING TESTIMONY Name of Organization Presented Testimony at Public Hearinga ARA Living Centers Academy for Health Services Marketing Administration on Aging, Department of Health and Human Service Aetna Life Insurance Corporation American Academy of Facial Plastic and Reconstructive Surgery American Academy of Family Physicians American Academy of Home Care Physicians American Academy of Orthopaedic Surgeons American Academy of Otolaryngology-Head and Neck Surgery American Academy of Physical Medicine and Rehabilitation DC
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American Psychiatric Association American Psychological Association American Red Cross American Society for Gastrointestinal Endoscopy American Society for Parenteral & Enteral Nutrition SF DC DC DC DC DC DC DC DC
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Federation of American Health Systems Georgetown University School of Nursing Gray Panthers of San Francisco Group Health Association of America, Inc. Health Care Purchasers Association Health Data Institute, Baxter Hewlett Packard Home Health Review - Erie County (New York)
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Zion Medical Center, Institute on Aging National Association of Healthcare Providers, Inc. National Association of Board of Examiners For Nursing Home Administrators National Alliance of Senior Citizens National Association for Home Care National Association of Private Psychiatric Hospitals National Association of Quality Assurance Professionals National Association of Retired Federal Employees National Association of Social Workers National Center for Nursing Research, National Institutes of Health National Council on the Aging, Inc.
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Professional Review Organization for Washington Professional Review Organization for Washington, Alaska Division Pacific Telesis Paralyzed Veterans of America Pharmaceutical Manufacturers Association Prospective Payment Assessment Commission Providence Hospital (Anchorage, Alaska) Public Citizens Health Research Group Sanford Feldman, M.D.
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