type: other

jurisdiction: US

text: b' Department of HeaIth and Human Services\n\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\n THE MEDICARE PEER REVIEW\n ORGANIZATIONS\xe2\x80\x99 ROLE\n IN IDENTIFYING AND RESPONDING\n TO POOR PERFORMERS\n\n\n\n\n &\n #sSERVICtx\n %9\n +\n $\n ~ JUN13 GIBBS BROWN\n 22 Inspector General\n %\n 2\xe2\x80\x994+ <\n %@a\n 2\xe2\x80\x94 DECEMBER 1995\nI OEI-01-93-()()251\n\n\n \xe2\x80\x94\n\x0c OFFICE OF INSPECTOR GENERAL\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as\namended, is to protect the integrity of the Department of Health and Human Services\xe2\x80\x99 (HHS)\nprograms as well as the health and welfare of beneficiaries served by those programs. This\nstatuto~ mission is carried out through a nationwide network of audits, investigations, and\ninspections conducted by three OIG operating components: the Office of Audit Services, the\nOffice of Investigations, and the Office of Evaluation and Inspections. The OIG also informs the\nSecretary of HHS of program and managementproblems and recommends courses to correct them.\n\n OFFICE OF AUDIT SERVICES\n\nThe OIG\xe2\x80\x99SOffice of Audit Services (OAS)provides all auditing services for HHS, either by\nconducting audits with its own audit resources or by overseeing audit work done by others. Audits\nexamine the performance of HHS programs and/or its grantees and contractors in carrying out\ntheir respective responsibilities and are intended to provide independentassessmentsof HHS\nprograms and operations in order to reduce waste, abuse, and mismanagementand to promote\neconomy and efficiency throughout the Department.\n\n OFFICE OF INVESTIGATIONS\n\nThe OIG\xe2\x80\x99SOffice of Investigations(01) conducts criminal, civil, and administrative investigations\nof allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment\nby providers. The investigative efforts of 01 lead to criminal convictions, administrative\nsanctions, or civil money penalties. The 01 also oversees State Medicaid fraud control units which\ninvestigate and prosecute fraud and patient abuse in the Medicaid program.\n\n OFFICE OF EVALUATION AND INSPECTIONS\n\nThe OIG\xe2\x80\x99SOffice of Evaluation and Inspections (OEI) conducts short-term management and\nprogram evaluations (called inspections)that focus on issues of concern to the Department, the\nCongress, and the public. The findings and recommendationscontained in these inspection reports\ngenerate rapid, accurate, and up-to-date information on the efficiency, vulnerability, and\neffectiveness of departmental programs. This report was prepared in the Boston regional ofilce\nunder the direction of Mark R. Yessian, Ph.D., Regional Inspector General, and Martha B. Kvaal,\nDeputy Regional Inspector General. Project staff included:\n\nBOSTON HEADQUARTERS\n\nJoyce M. Greenleaf, Project Leader Barbara Tedesco, Technical Support StaJf\nElizabeth A. Robboy\n\x0cDepartment of Health and Human Services\n\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\n THE MEDICARE PEER REVIEW\n\n ORGANIZATIONS\xe2\x80\x99 ROLE\nIN IDENTIFYING AND RESPONDING\n TO POOR PERFORMERS\n\n\n\n\n\n ~.t$\n #sSERVIC6$\n ~tv\n\n $\n ; JUNE GIBBS BROWN\n s Inspector General\n %\n %\n a+ <\n \xe2\x80\x9chd$a\n 2 DECEMBER 1995\n OEI-01-93-()()251\n\n\x0c EXECUTIVE SUMMARY\n\n\nPURPOSE\n\nTo assess the ability of the Medicare Peer Review Organizations to identify and respond\nto poorly performing physicians and hospitals at a time when their primary mission is to\nimprove the overall quality of medical care.\n\nBACKGROUND\n\nIn carrying out their mission to protect Medicare beneficiaries, the Peer Review\n\nOrganizations (PROS) perform two basic functions. One is to contribute to improving the\n\noverall practice of medicine by working collegially with the medical community in\n\nanalyzing patterns of care and outcomes. Their focus is on the systems of care rather than\n\nindividual caregivers. The other function is to identify and respond to poorly performing\n\nphysicians or hospitals by reviewing individual instances of questionable care and by\n\ntaking follow-up actions they deem appropriate. The former function, which aims to\n\nimprove care overall, dominates. The latter function, to identify and deal effectively with\n\npoor performers, has always faced major constraints, many of which have been\n\nhighlighted in prior Office of Inspector General (OIG) reports.\n\n\nThis report draws on data from surveys of 22 PROS representing 72 percent of the\n\nbeneficiary population in the country, on aggregate data from HCFA reflecting all the\n\nPROS\xe2\x80\x99 record review workload under the fourth contract, on telephone calls with officials\n\nfrom 10 State medical boards, and on information from our previous PRO inquiries.\n\n\nFINDINGS\n\nAs the PRO Program becomes increasingly committed to improving the overall practice\nof medicine, its ability to find and take action on poorly peiforrning physicians and\nhospitals is questionable.\n\nF\t Limited Leads. The PROS find themselves with very limited leads to identify\n poorly performing physicians or hospitals. The PROS rely on beneficiary\n complaints, referrals from the medical community, and newer approaches to\n identify poor performers. However, the beneficiary complaint process, as we\n indicated in a recent report, has signiilcant flaws; the referrals from the medical\n community remain minimal; and the new approaches have identified few leads.\n\nE\t Limited Analysis. Once the PROS become aware of an instance of questionable\n care, they are unlikely under their current contracts to determine if it is an isolated\n event or part of a pattern of such care. The PROS do have the authority to collect\n and analyze such data. Their priorities, however, are elsewhere.\n\n\n\n\n i\n\x0cF\t Limited Follow-Up. During their current contracts with HCFA, 10 of the 22\n PROS in our sample had not initiated any improvement plans that compel\n individual physicians or hospitals to address the quality-of-care problems. The\n other 12 initiated improvement plans in response to 146 quality-of-care\n -. problems.\n One PRO identified half of those problems:\n\nk\t Moribund Sanction Recommendations. The PROS\xe2\x80\x99 sanction recommendations to\n the Office of Inspector General have dwindled from a high of 72 in FY 1987 to\n 12, 14, 13 and 13 in FYs 1991 through 1994.\n\nF\t Minimal Referrals to State Medical Boards. In 1993, Congress passed\n legislation requiring PROS to share information with medical boards on physicians\n found to be responsible for serious quality-of-care problems. The legislation\n appears to have had little, if any, impact on the level of such sharing.\n\nThe PROS themselves find much that is positive about the current direction of the\nProgram. But some express reservations about its impact on protecting Medicare\nbeneficiaries from poor performers.\n\n\xef\xbf\xbd\t Compatible Functions. Seventeen of the 22 PROS (77 percent) in our sample\n indicated that the two basic PRO functions--improving the mainstream of care and\n dealing with poor performers--are compatible.\n\nb\t Weakened Protections. Yet, when questioned further, 11 of 22 PROS\n (50 percent) concluded that beneficiary protections have become weaker. This\n compares to 5 (23 percent) that concluded protections have become stronger,\n 4 (18 percent) that concluded protections have remained about the same, and\n 2 (9 percent) that did not know.\n\nRECOMMENDATION\n\nOur inquiry does not question the PRO Program\xe2\x80\x99s focus on improving the mainstream of\ncare; nor does it reflect a desire to return to an emphasis on random medical record\nreviews. We recognize that the random reviews were labor-intensive, generated much\ndiscord with the medical community, and identified few quality-of-care problems relative\nto the numbers of records reviewed. We also understand that the premise of the PRO\nProgram\xe2\x80\x99s current direction holds promise for improving the overall practice of medicine.\nThis is of great importance to Medicare beneficiaries and others.\n\nYet, we find sufficient basis to question the responsiveness of the PRO Program to its\nother traditional function: identifying and responding to physicians and hospitals that fail\nto meet minimally acceptable standards of care. We direct our recommendation to this\nvulnerability.\n\nWe recommend that HCFA reconsider the PROS\xe2\x80\x99 function to identi! and respond\neffectively to poorly pe~orming physicians and hospitals.\n\n\n ii\n\x0cThere needs to be a public discussion on what existing or potential processes could deal\neffectively with poor performers. To further that public discussion, we offer two options\nfor HCFA to consider based on the premise that the PROS\xe2\x80\x99 emphasis on improving care\noverall will remain dominant:\n\n OPTION 1\n\n\xef\xbf\xbd The HCFA should proceed toward directing the PROS to focus exclusively on\nimproving the mainstream of care. To help deal with poor performers, it should\nconsider ways in which the Federal government might support other bodies, such as\nState medical boards and ombudsmen, that are more focused on addressing individual\ncases of poor medical care.\n\n Pros.o Could clarify the PROS\xe2\x80\x99 mission and thereby contribute to improved\n performance. Could make PROS\xe2\x80\x99 mission consistent with their funded and\n operational priorities. Could contribute to more effective performance by other\n bodies focussing on poor performers.\n\n Cons: Could undermine improvement efforts by removing what some regard as a\n complementary function of the PROS, Could weaken the PROS\xe2\x80\x99 authority with the\n medical community. Could endanger beneficiaries if others fail to deal effectively\n with poor performers.\n\n OPTION 2\n\n\xef\xbf\xbd The HCFA should devote further inquiry to determine: (1) if the two functions\nof improving the mainstream of care and identifying and dealing effectively with poor\nperformers can reasonably be perfo~ed by one organization, and (2) how PROS can\ncarry out both simultaneously. Toward this end, it could suppoti research efforts,\ndemonstration projects by individual PROS, and conferences.\n\n Pros: Could lead to a better understanding of the two fimctions\xe2\x80\x99 compatibility.\n Could identify benchmark practices among the PROS. Could lead to innovation in\n how PROS achieve both functions.\n\n Cons: Could delay inevitable decisions about the direction and role of the PRO\n Program. Could call for additional resources or siphon resources away from\n improvement projects. Could restrict PROS from effectively performing either\n function.\n\nCOMMENTS ON THE DRAFT REPORT\n\nWe solicited and received comments on the draft report from the Health Care Financing\nAdministration (HCFA), the American Medical Peer Review Association (AMPRA), the\nAmerican Medical Association (AMA), the American Association of Retired Persons\n(AARP), the Public Citizen Health Research Group (hereafter referred to as Public\n\n ,..\n 111\n\x0cCitizen), and the Coalition for Consumer Protection and Quality in Health Care Reform\n(hereafter referred to as the Coalition). We include the complete text of the detailed\ncomments in appendix E. Below we summarize the major comments of the respondents\nand then, in italics, offer our responses. In the report, we made minor edits in response\nto comments.\n\nThe HCFA concurred with our recommendation, found merit in both options, and asked\nus to call for a public discussion on the issues. It also expressed concerns about our\ndiscussion of the PROS\xe2\x80\x99 limited efforts in identifying patterns of poor care and our\npresentation of the survey data on weakened protections. The AMPRA supported option\n2, believing it is premature to focus PRO activity exclusively on improving the\nmainstream. The AMPRA believes the two functions are compatible and that the quality\nimprovement approach holds promise for dealing with poor performers, giving several\nexamples of successful projects. The AMA indicated that it had no firm position on either\noption and noted that the primary focus of the PRO program should be improving the\nmainstream of care. The AARP disagreed with option 1 because of its strong belief that\nPROS retain their responsibility to identify and respond to poor performers. Public\nCitizen also disagreed with option 1, noting that while continuous quality improvement is\na welcome addition to beneficiary protections, it cannot replace detecting poor performers.\nPublic Citizen supported further study as outlined under option 2, The Coalition, while\nreserving final judgment on the options, indicated it has concerns about the PROS\xe2\x80\x99 ability\nto provide adequate beneficiary protections given the dominance of their function to\nimprove the overall practice of medicine.\n\n We appreciate HCFA\xe2\x80\x99s suppoti for our recommendation and have added language calling\nfor a public discussion. With respect to HCFA\xe2\x80\x99s concern about our discussion of limited\n e~orts, we have edited our text to re~ect that PROS have the authority to collect and\n analyze data. With respect to its concern about our presentation of the survey data on\n weakened protections, we have attempted to provide appropriate context for inte~reting\n the survey data. We agree with AMPRA that continuous quali~ improvement holds\npromise for the overall practice of medicine. Our concern, however, is that with the\n PROS\xe2\x80\x99 focus on such systems-oriented approaches Medicare beneficiaries remain\n vulnerable to harm from individual poor performers. We appreciate all the comments on\n our drafi report and urge continued discussion on the roles PROS can play in protecting\n Medicare bene$ciaries from poorly pe~orming physicians and hospitals.\n\n\n\n\n iv\n\x0c PAGE\nEXECUTIVE SUMMARY\n\n\nINTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1\n\n\nFINDINGS\n\n\n \xef\xbf\xbd Questionable Protections from Poor Care . . . . . . . . . . . . . . . . . . . . .+.. . . 3\n\n\n \xef\xbf\xbd Reservations AboutProtectiom .t.,oc<.o......-. ., .oe. oo, ..,e..7\n\n\nRECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8\n\n\nCOMMENTS ON THE DRAFT REPORT . . . . . . . . . . . . . . . . . . . . . . ...10\n\n\nAPPENDICES\n\n\nA: Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-1\n\n\nB: PROs\xe2\x80\x99Sources for Identifying Quali~-of-Care Problems . . . . . . . . . . . . . . . .B-l\n\n\nc: Interventions Included in Improvement Plans . . . . . . . , . . . . . . . , . . . . . . .C-l\n\n\nD: Overview of Sanction Data from the Office of Inspector General . . . . . . . . . . D-1\n\n\nE: Complete Comments ontheDraft Report . . . . . . . . . . . . . . . . . . . . . . . ..E-1\n\n\nF: Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..F-l\n\n\x0c INTRODUCTION\n\n\n PURPOSE\n\n To assess the ability of the Medicare Peer Review Organizations to identify and respond\n to poorly performing physicians and hospitals at a time when their primary mission is to\n improve the overall quality of medical care.\n\n BACKGROUND\n\n In April 1993, the Medicare Peer Review Organizations (PROS) began implementing their\n fourth contracts with the Health Care Financing Administration (HCFA). These contracts\n marked major changes in the PROS\xe2\x80\x99 aims and operations. The PROS now aim to improve\n the overall practice of medicine. They do this by working collegially with the medical\n community in analyzing patterns of care and outcomes and by sharing their insights with\n that community. Their focus is now on the performance of systems of care rather than on\n individual caregivers.\n\n The HCFA refers to this initiative as the Health Care Quality Improvement Program\n (HCQIP). The HCQIP rests heavily on the precepts of continuous quality improvement,\n which hold that it is far more important to improve the overall performance levels even\n slightly than it is to identify and address poor performers at the margin. This emphasis\n reflects the kind of redirection called for by the Institute of Medicine in its comprehensive\n assessment of Medicare quality assurance efforts. 1\n\n Prior to the fourth contracts, the PROS sought to ensure the necessity, quality, and\n appropriateness of care rendered to Medicare beneficiaries by identifying and addressing\n individual clinical problems. They did this by reviewing individual instances of\n questionable care that they had identified through random medical record reviews or\n beneficiary complaints. At times, the PROS\xe2\x80\x99 reviews represented as much as 15 percent\n of Medicare hospital discharges. Once they confirmed a quality-of-care problem, they\n addressed it by taking follow-up actions they deemed appropriate. At the extreme, such\n actions could involve recommending a sanction to the Office of Inspector General (OIG).\n\n Thus, with the start of the fourth contract, the PROS began to perform two basic\n functions. The dominant function, however, is the function aimed at improving the\n overall practice of medicine. During the past 2 years, the HCFA has increasingly stressed\n it. At the same time, HCFA continues to rely on the PROS to safeguard Medicare\n beneficiaries by identifying and dealing effectively with individual poor performers. This\n function has always faced major constraints, many of which have been highlighted in prior\n reports by the Office of Inspector General .2 In fact, in our prior report, The Beneficiary\n Complaint Process of Medicare Peer Review Organizations, we assess the beneficiary\n complaint process--a- key safety valve for beneficiaries. In that report, we found that\n while the complaint process represented an important source of information on poor\n\n\n\n 1\n\n\n\n\xe2\x80\x94 \xe2\x80\x94\n\x0cperformers, it has some flaws that undermine its effectiveness. We offered\nrecommendations to HCFA for improving the process as a near-term solution.\n\nIn this report, we use the term poor performers to refer to physicians whose medical\nknowledge and/or practice skills are below minimally acceptable standards (as determined\nby the medical community) and who, therefore, pose a continuing threat to the safety of\ntheir patients. With respect to hospitals, we refer to those institutions having insufficient\ninternal systems to ensure that patients are receiving minimally acceptable standards of\ncare.\n\nIn this report, we look more broadly at the effectiveness of the PROS in addressing\nindividual poor performers at a time when their focus stresses dealing with system\nimprovements. We conclude with a recommendation that supports long-term strategies for\ndealing with poorly performing physicians and hospitals that fail to meet minimally\nacceptable standards of care.\n\nMETHODOLOGY\n\nWe relied on 4 sources of information: (1) surveys of 22 PROS representing 72 percent\n\nof the beneficiary population in the country, (2) aggregate data from HCFA reflecting all\n\nPROS\xe2\x80\x99 medical record reviews completed under the fourth contract and through\n\nJune 30, 1994, (3) telephone calls with officials from 10 State medical boards, and\n\n(4) cumulative information gathered through our previous inquiries on the PROS. (See\n\nappendix A for a more detailed discussion of our methodology.)\n\n\nUnless noted, the data presented are based on the PROS\xe2\x80\x99 experiences under their fourth\n\ncontract with HCFA.\n\n\nHereafter, we use the term quality-of-care problem to refer to a problem identified by a\n\nPRO through any source for which (1) the PRO gave the physician or hospital responsible\n\nan opportunity to discuss and/or give additional information about the care in question and\n\n(2) the PRO\xe2\x80\x99s physician reviewer(s) reviewed the record and confirmed that a problem\n\nhad occurred.\n\n\nWe conducted our review in accordance with the Quality Standards for Inspections issued\n\nby the President\xe2\x80\x99s Council on Integrity and Efficiency.\n\n\n\n\n\n 2\n\n\x0c FINDINGS\n\n\n As the PRO Program becomes increasingly committed to improving the overall practice\n of medicine, its ability to find and take action on poorly performing physicians and\n hospitals is questionable.\n\n \xef\xbf\xbd Limited Leads. The PROS find themselves with very limited leads to identify\n poorly performing physicians or hospitals. With the phasing out of the random\n sample medical record review, which has been the primary source for identifying\n poor performers, PROS still have other sources for identifying poor performers.\n These include beneficiary complaints, referrals from the medical community, and\n newer approaches developed under HCQIP. However, the beneficiary complaint\n process, as we indicated in a recent report, has significant flaws; the referrals from\n the medical community remain minimal; and the new approaches have identified\n few leads.\n\n The 53 PROS identified 6,010 cases with quality-of-care problems for reviews completed\n between April 1993 and June 1994.3 The majority of these (71 percent) came from the\n 5 percent inpatient random sample medical record review. Yet the random sample has\n been, at best, an inefficient source for identifying leads, as less than 1 percent of all\n random sample reviews led to quality-of-care problems.4 By October 1995, that random\n sample will be completely phased out .5 In our recent survey of 22 PROS, 17 (77 percent)\n judged this reduction in record review as a major barrier to identifying individual quality-\n of-care problems.\n\n The PROS will continue to review those records mandated by law, such as those for\n quality-related beneficiary complaints. b Of the 6,010 quality-of-care problems identified\n by PROS, 9 percent came from the mandatory reviews overall and 2 percent from\n beneficiary complaints (see appendix B). In our prior report, we found that complaints\n can, in fact, be an important source for identifying quality-of-care problems. But our\n inspection also revealed that many beneficiaries were unaware of the opportunities to\n complain to PROS about the quality of their medical care and that PROS received too few\n complaints to identify meaningful patterns of poor care.7\n\n Further, the PROS have received few referrals from the medical community. In our\n survey of 22 PROS, 6 reported they had received referrals from their State medical\n boards; none of these referrals led to quality-of-care problems.g Eight PROS reported\n they had received referrals from hospitals and 13 from physicians; these referrals led to\n quality-of-care problems in 5 PROS.9 For those 5 PROS, though, the referrals accounted\n for less than 2 percent of all the PROS\xe2\x80\x99 quality-of-care problems. At the time of our\n survey, none of the 22 PROS had written policies encouraging referrals from physicians,\n hospitals, or medical boards.\n\n Finally, the PROS have identified few leads through their activities begun under the Health\n Care Quality Improvement Program (HCQIP), including the cooperative projects aimed at\n\n\n 3\n\n\n-.\n\x0cimproving overall care. Four of the 22 PROS in our sample identified quality-of-care\nproblems through such projects and their related data collection, even though these\nprojects were not designed to identify poor performers. For those 4 PROS, though, the\nproblems identified through cooperative projects accounted for less than 2 percent of all\nthe PROS\xe2\x80\x99 quality-of-care problems. The other 18 PROS identified no leads through such\nprojects.\n\n\xef\xbf\xbd\t Limited Analysis. Once the PROS become aware of an instance of questionable\n care, they are unlikely under their current contracts to determine if it is an isolated\n event or part of a pattern of such care. The PROS have little medical data to draw\n upon to assess an individual physician\xe2\x80\x99s or hospital\xe2\x80\x99s prior performance. The\n PROS do have the authority to collect and analyze such data. However, with\n HCFA\xe2\x80\x99s emphasis on cooperative projects that aim to improve the mainstream of\n care, PROS are unlikely to devote resources to tracking a questionable provider\xe2\x80\x99s\n fbture performance.\n\nIt is one thing to obtain a possible lead on a possible poor performer. It is quite another\nto conduct the analysis to determine if (1) a pattern exists that exposes Medicare\nbeneficiaries to undue danger and (2) some kind of follow-up action should be taken.\nMaking such a determination is a resource-intensive and often adversarial process that\nruns counter to the tenets of continuous quality improvement. It is an allowable activity\nfor expenditure of PRO program finds, but is clearly not a priority under HCFA\xe2\x80\x99S current\ncontracts with the PROS.\n\nThrough our survey, the PROS cited limitations in conducting the analysis necessary to\ndistinguish patterns of poor performance from isolated incidents of poor care. In fact,\nofficials from 16 of the 22 PROS we surveyed judged difficulties in establishing patterns\nof poor care as a major barrier to establishing improvement plans with individual\nphysicians or hospitals. They must rely primarily on their historical data bases that\ninclude past PRO reviews. But with the reduced medical record review, these data bases\nare losing relevance. 10 And PROS reported that they rarely initiated projects under the\nHCQIP to determine whether problems were isolated or part of patterns. None of the\n22 PROS reported routinely conducting special data collection to determine if the problems\nwere isolated.\n\nk\t Limited Follow-Up. Currently, once PROS confirm (through medical record\n review) that physicians or hospitals are responsible for quality-of-care problems,\n they rarely do anything more than inform those responsible of the nature of the\n problem. During their current contracts with HCFA, 10 of the 22 PROS in our\n sample had not initiated any improvement plans that compel individual physicians\n or hospitals to address the quality-of-care problems. The other 12 initiated\n improvement plans in response to 146 quality-of-care problems. One PRO\n identified half of those problems.\n\nThe 22 PROS in our sample responded to all the quality-of-care problems they confirmed.\nFor 99 percent of those problems, the PROS responded with a letter confirming, after\n\n\n 4\n\x0cmedical record review, that a quality-of-care problem occurred. 11 In only 1 percent of\nthe problems did the PROS respond with more than a letter. These involved 146 problems\nand 12 of the 22 PROS in our sample. The PROS responded to these problems with\nimprovement plans designed to prevent the recurrence of the problem. 12 These plans\ncompelled those involved to take some action, such as attend a course (for a physician) or\nconduct inservice training (for a hospital).\n\nThe number of quality-of-care problems the 12 PROS responded to with improvement\nplans ranged from 1 to 73, with a median of 6.5. Six PROS responded to 5 or fewer\nproblems with improvement plans, 2 PROS responded to between 6 and 10 problems with\nplans, and 3 PROS responded to between 11 and 15 problems with plans. One PRO\nresponded to 73 problems with improvement plans, accounting for half of the responses in\nour sample.\n\nOf the 146 problems the 12 PROS responded to with improvement plans, 77 involved\nplans directed to physicians and 69 to hospitals. Based on our review of 53 of these\nimprovement plans, we found that most of those directed to hospitals involved a systemic\nintervention such as a review of or change in the hospital\xe2\x80\x99s policies. Most of those\ndirected to physicians included an educational component such as continuing medical\neducation or inservice training (see appendix C).\n\nThe extent to which physicians are subject to any corrective or disciplinary actions by\nhospital quality assurance bodies is unclear. However, given that such actions run counter\nto the collegial and self-improvement precepts of continuous quality improvement, it is\nlikely to be minimal. In fact, another Office of Inspector General inspection raises\nimportant questions about the extent to which hospitals themselves have taken adverse\nactions directed to physicians. 13 In that inspection, we found that 75 percent of the\nhospitals in the United States reported no adverse actions to the National Practitioner Data\nBank from September 1, 1990 to December 31, 1993.14\n\nF\t Moribund Sanction Recommendations. The sanction referral authority has\n continued in the moribund state we reported on in 1993. The PROS\xe2\x80\x99 sanction\n recommendations to the Office of Inspector General have dwindled from a high of\n 72 in FY 1987 to 12, 14, 13 and 13 in FYs 1991 through 1994. By contrast, State\n medical boards have become much more active in disciplining poorly performing\n physicians. From CY 1991 to CY 1994, annual board actions increased from\n 2,804 to 3,571.\n\nFrom FY 1986 through 1994, the OIG sanctions have shown a similar decline: from a\nhigh of 50 in FY 1987 to a low of 6 in FY 1992, 10 in FY 1993, and 7 in FY 1994. In\nthis period, 159 physicians have been sanctioned compared to 3 hospitals (see appendix\nD).\n\nAs we reported in 1993, the drop in PRO sanction recommendations can be explained by\nthree factors: (1) the statutory requirement that prevents sanction unless providers have\ndemonstrated an \xe2\x80\x9cunwillingness or lack of ability\xe2\x80\x9d to comply with their Medicare\n\n\n 5\n\x0cobligations; (2) the PROS\xe2\x80\x99 cumulative experience with the costly, complex, and\ncontentious referral process; and (3) their increasing emphasis on educational rather than\npunitive responses to poor care. Is The OIG\xe2\x80\x99S high rate of rejections also helps explain\nthe decline. From FY 1986 through FY 1994, the OIG rejected 41 percent of the PROS\xe2\x80\x99\nsanction recommendations based on either willingness and ability, failure to follow the\nregulatory requirements, or lack of medical evidence (see appendix D),\n\nLike PROS, State medical boards have a responsibility for ensuring quality of medical\ncare. But, unlike PROS, State boards deal with care provided by licensees to all their\npatients, not just those covered by Medicare. The HCFA requires that, as a condition of\nparticipating in Medicare, physicians be licensed by their States. And as PRO sanction\nrecommendations have dropped, medical board actions to discipline physicians have\nincreased. Unlike OIG sanctions, which bar participation in Medicare and Medicaid but\ndo not affect licensure, medical board actions can affect a physician\xe2\x80\x99s license to practice.\nFor example, in CY 1994, State boards took 3,571 actions of which 1,498 (42 percent)\ninvolved the loss of license, including revocation, suspension, surrender, or mandatory\nretirement. Another 1,256 of those actions (35 percent) involved some restriction to the\nlicense, such as probation or limitation. The remaining actions involved modifications to\nthe licenses that resulted in some penalty or reprimand to the physicians. 16\n\n\xef\xbf\xbd\t Minimal Referrals to State Medical Boards. In 1993, Congress passed\n legislation requiring PROS to share information with medical boards on physicians\n found to be responsible for serious quality-of-care problems. The legislation\n appears to have had little, if any, impact on the level of such sharing.\n\nIn April 1993, we reported that the PROS\xe2\x80\x99 sharing of case information, even for the most\nserious cases, was minimal .17 The Citizen Advocacy Center also reported on the\nminimal level of sharing based on its 2 surveys in 1992, one that reviewed the experiences\nof 10 States where PROS and medical boards both had shown an interest in sharing and a\nsecond, more extensive survey of all 50 States. 18 Between its two surveys, the Center\nfound that in only Ohio, Mississippi, New York, and to a lesser extent Texas, was much\ninformation being sent to the medical boards.\n\nTo assess the current level of sharing, we called the medical boards in the 10 States\nidentified by the Center with boards and PROS committed to sharing information. 19 We\nfound that sharing remains minimal. No board official reported an increase in the level of\nsharing. Officials from 3 of those 10 States--including Ohio and Mississippi--reported that\nthe level of sharing was less than what they had reported to the Center in 1992. Five\nreported the level of sharing was about the same. Two were unable to answer due to a\nlack of data.\n\n\n\n\n 6\n\n\x0cThe PROS themselves find much that is positive about the current direction of the\nProgram. But some express reserv@\xe2\x80\x9dons about its impact on protecting Medicare\nbeneficiaries from poor pe~ormers.\n\n\xef\xbf\xbd\t Compatible Functions. Seventeen of the 22 PROS (77 percent) in our sample\n indicated that the two basic PRO functions--improving the mainstream of care and\n dealing with poor performers--are compatible.\n\nF\t Weakened Protections; Yet, when questioned further, 11 of 22 PROS\n (50 percent) concluded that beneficiary protections have become weaker. This\n compares to 5 (23 percent) that concluded protections have become stronger,\n 4 (18 percent) that concluded protections have remained about the same, and\n 2 (9 percent) that did not know.\n\nSeveral PRO officials explained the functions\xe2\x80\x99 compatibility by noting that improving care\noverall also improves the poor performers. They pointed out that problems they identify\nwith poor performers become opportunities for cooperative projects aimed at overall\nimprovement. Indeed, according to some officials with whom we spoke, it is the PROS\xe2\x80\x99\nclout as the entities that deal with poor performers that can convince reluctant hospitals to\nparticipate in improvement projects. Others noted that compatibility means not pursuing\nminor problems while reserving resources for those outlier physicians and hospitals that\npose significant threat to do great harm. In fact, some said that hospital officials welcome\nthe PROS and rely on them for help in identifying and dealing with poor performers.\n\nYet, while the PROS reflect strong support for the compatibility of the two fi.mctions, they\nalso point to weakened protections for the beneficiary. Twice as many PRO officials\nconcluded protections have weakened since the third contract than concluded they have\nstrengthened. Many in the PRO community with whom we spoke tied the weakened\nprotections directly to their lessened ability to conduct medical record reviews. They\nreported that without funding and authority for some minimal level of record review,\ninstances and patterns of poor care have gone undetected and therefore unaddressed. And\nalthough its value was never definitively documented, some PROS questioned if the\nsentinel effect--whereby the mere knowledge of ongoing medical record reviews creates an\nincentive to improve care with the medical community--will exist as record review\ndeclines.\n\n\n\n\n 7\n\n\x0c RECOMMENDATION\n\n\n Our inquiry does not question the PRO Program\xe2\x80\x99s focus on improving the mainstream of\n\n care; nor does it reflect a desire to return to an emphasis on random medical record\n\n reviews. We recognize that the random reviews were labor-intensive, generated much\n\n discord with the medical community, and identified few quality-of-care problems relative\n\n to the numbers of records reviewed. We also understand that the premise of the PRO\n\n Program\xe2\x80\x99s current direction holds promise for improving the overall practice of\n\n medicine .20 This is of great importance to Medicare beneficiaries and others.\n\n\n Yet, we find sufficient basis to question the responsiveness of the PRO Program to its\n\n other traditional function: identifying and responding to physicians and hospitals that fail\n\n to meet minimally acceptable standards of care. We direct our recommendation to this\n\n vulnerability.\n\n\n We recommend that HCFA reconsider the PROS\xe2\x80\x99 function to identi$y and respond\n effectively to poorly pe~orming physicians and hospitals.\n\n There needs to be a public discussion on what existing or potential processes could deal\n effectively with poor performers. To further that public discussion, we offer two options\n for HCFA to consider based on the premise that the PROS\xe2\x80\x99 emphasis on improving care\n overall will remain dominant:\n\n OPTION 1\n\n b The HCFA should proceed toward directing the PROS to focus exclusively on\n improving the mainstream of care. To help deal with poor performers, it should\n consider ways in which the Federal government might support other bodies, such as\n State medical boards and ombudsmen, that are more focused on addressing individual\n cases of poor medical care.\n\n Pros: Could clarify the PROS\xe2\x80\x99 mission and thereby contribute to improved\n performance. Could make PROS\xe2\x80\x99 mission consistent with their funded and\n operational priorities. Could contribute to more effective performance by other\n bodies focussing on poor performers.\n\n Cons: Could undermine improvement efforts by removing what some regard as a\n complementary fimction of the PROS. Could weaken the PROS\xe2\x80\x99 authority with the\n medical community. Could endanger beneficiaries if others fail to deal effectively\n with poor performers.\n\n OPTION 2\n\n F The HCFA should devote further inquiry to determine: (1) # the two functions\n of improving the mainstream of care and identifying and dealing effectively with poor\n\n\n 8\n\n\n\xe2\x80\x94\n\x0cperformers can reasonably be pe~ormed by one organization, and (2) how PROS can\ncarry out both simultaneously. Toward this end, it could suppoti research efforts,\ndemonstration projects by individual PROS, and conferences.\n\n Pros: Could lead to a better understanding of the two functions\xe2\x80\x99 compatibility.\n Could identify benchmark practices among the PROS. Could lead to innovation in\n how PROS achieve both functions.\n\n Cons: Could delay inevitable decisions about the direction and role of the PRO\n Program. Could call for additional resources or siphon resources away from\n improvement projects. Could restrict PROS from effectively performing either\n functions.\n\n\n\n\n 9\n\n\n \xe2\x80\x94\xe2\x80\x94-\n\x0c COMMENTS ON THE DRAFT REPORT\n\n\n We solicited and received comments on the draft report from the Health Care Financing\n Administration (HCFA), the American Medical Peer Review Association (AMPRA), the\n American Medical Association (AMA), the American Association of Retired Persons\n (AARP), the Public Citizen Health Research Group (hereafter referred to as Public\n Citizen), and the Coalition for Consumer Protection and Quality in Health Care Reform\n (hereafter referred to as the Coalition). We include the complete text of the detailed\n comments in appendix E. Below we summarize the major comments of the respondents\n and then, in italics, offer our responses. In the report, we made minor edits in response\n to comments.\n\n The HCFA concurred with our recommendation to reconsider the PROS\xe2\x80\x99 function to\n identify and respond to poor performers. It found merit in both options and asked that we\n call for a public discussion on these issues. It expressed concerns about our discussion of\n the PROS\xe2\x80\x99 limited efforts in identifying patterns of poor care, pointing out that PROS have\n the authority and opportunity to perform primary data collection if they find an instance of\n questionable care. The HCFA also expressed concerns that our presentation of the survey\n data on weakened protections would lead other readers to conclude we advocate a return\n to case review, although it understood that we did not.\n\n We appreciate HCFA\xe2\x80\x99s suppoti for our recommendation. Based on HCFA\xe2\x80\x99s suggestion,\n we added language calling for a public discussion in introducing the two options. With\n respect to HCFA\xe2\x80\x99s concerns about our discussion of the PROS\xe2\x80\x99 limited e~orts concerning\n problem analysis, we point out that our text specifies such analysis is an eligible program\n expense. We have edited that text to muke clear that PROS in fact have the authori~ to\n conduct such analysis. With respect to HCFA\xe2\x80\x99s concerns about our presentation of the\n survey data on weakened protections, we have attempted to provide the appropriate\n context so that it is clear to readers that we do not advocate a return to case review.\n\n The AMPRA supported option 2, believing it is premature to focus PRO activity\n exclusively on improving the mainstream. The AMPRA believes the two functions are\n compatible and that the quality improvement approach holds promise for dealing with poor\n performers, giving several examples of successful improvement projects. The AMPRA\n also called for strengthened PRO interactions with medical boards, ombudsmen, licensing\n agencies, and accrediting bodies.\n\n We agree with AMPRA that continuous quality improvement holds promise for the overall\n practice of medicine, as in the systems-oriented examples AMPRA cites. Our concern,\n however, is that with the PROS\xe2\x80\x99 focus on such systems-oriented approaches, Medicare\n beneficiaries remain vulnerable to harm from those individuals whose medical knowledge\n andlor practice skills are below minimally acceptable standards.\n\n The AMA indicated that it had no firm position on either option and noted that the\n primary focus of the PRO program should be improving the mainstream of care. The\n\n\n 10\n\n\n\xe2\x80\x94\xe2\x80\x94. .. \xe2\x80\x94.. \xe2\x80\x94.\xe2\x80\x94.. \xe2\x80\x94\xe2\x80\x94____\n\x0cAARP disagreed with option 1 because of its strong belief that PROS retain their\nresponsibility to identify and respond to poor performers. Public Citizen also disagreed\nwith option 1, noting that while continuous quality improvement is a welcome addition to\nbeneficiary protections, it cannot replace detecting poor performers. Public Citizen also\nnoted that while it supports further study as outlined under option 2, recommendations\nmade in previous OIG studies should be vigorously implemented. The Coalition, while\nreserving final judgment on the options, indicated it has concerns about the PROS\xe2\x80\x99 ability\nto provide adequate beneficiary protections given the dominance of their fimction to\nimprove the overall practice of medicine.\n\nWe appreciate these comments on our draft report and urge continued discussion on roles\nPROS can play in protecting Medicare beneficiaries from poorly pe~orming physicians\nand hospitals.\n\n\n\n\n 11\n\n\x0c APPENDIX A\n\n\n METHODOLOGY\n\nMail and Telephone Surveys of 22 PROS\n\nWe conducted mail and telephone surveys with 22 PROS in January 1995. We chose\nthese PROS through a stratified sample in which we arrayed PROS according to the\nnumber of Medicare beneficiaries in each State (high and low beneficiary population).\nWe chose all 17 of the PROS for States in the high-population stratuml and a random\nsample of 5 PROS for States in the low-population stratum.z The PROS in our sample\nrepresent 72 percent of the Medicare beneficiary population in the country. The response\nrate for both the telephone interviews and the mail survey was 100 percent.\n\nWe sent out a mail survey to all 22 PROS in which we asked PROS for specific data under\nthe fourth contract. The data included sources for confirmed quality-of-care problems and\nhow many such problems led to improvement plans, among others.\n\nWe supplemented the mail survey with more in-depth telephone interviews. For the\ninterviews, we designed and pretested a discussion guide with questions about identifying\nquality-of-care problems, the complaint process, barriers to identifying individual quality-\nof-care problems, responding to confirmed quality-of-care problems, and barriers to\nresponding to confirmed quality-of-care problems, among others.\n\nAggregate Data from HCFA\n\nWe also drew on data from HCFA\xe2\x80\x99S PROD3 data base (which includes the results of all\ninpatient record reviews) and PROD5 data base (which includes the results of all physician\nreviews). Through these we obtained data on the number and sources of confirmed\nphysician and hospital quality-of-care problems for all PROS for reviews completed under\nthe fourth contract through June 30, 1994.3 Our tests of the data revealed that 10 PROS\nreported no beneficiary complaints when, in fact, they had received such complaints.\n\n\n\n I These included the following States (listed in descending order of beneficiary\npopulation): California, New York, Florida, Pennsylvania, Texas, Ohio, Illinois,\nMichigan, New Jersey, North Carolina, Massachusetts, Missouri, Indiana, Georgia,\nVirginia, Wisconsin, and Tennessee.\n\n 2 These included the following States (listed in descending order of beneficiary\npopulation): New Mexico, Utah, Montana, South Dakota, and Delaware.\n\n 3 In analyzing our data on confirmed quality-of-care problems, we report the most\nconservative interpretations. We chose this approach to avoid double counting complaints\nthat resulted in confirmed problems with both a physician and a hospital.\n\n\n A-1\n\x0cNevertheless, when these data are viewed in the context of our telephone interviews and\nsurvey data, we believe the findings and recommendation in this report are valid.\n\nFollow-up with 10 State Medical Boards\n\nIn April 1995, we called the 10 State medical boards identified by the Citizen Advocacy\nCenter as sharing a commitment for increased sharing with the PROS in their States.4\nWe reviewed their previous level of sharing (as reported to the Center) and then asked\nthem to assess their current level of sharing as more, less, or about the same.\n\nPrevious Office of Inspector General Inquiries on PROS\n\nWe have an extensive history of reviewing the PRO Program, starting in 1988. The\nmajor studies we drew on in this report include: Peer Review Organizations and State\nMedical Boards: A Vital Link, OEI-C)I-92-00530, April 1993; The Sanction Referral\nAuthority of Peer Review Organizations, OEI-01-92-00250, April 1993; and, The\nBeneficiary Complaint Process of the Medicare Peer Review Organizations, Draft Report,\nOEI-01-93-00250, June 1995.5\n\n\n\n\n 4 The Center identified Alabama, California, Colorado, Iowa, Minnesota, Mississippi,\nOhio, Rhode Island, West Virginia, and Wisconsin as States with medical boards and\nPROS both committed to sharing information. (Citizen Advocacy Center, information\nExchange Between Peer Review Organizations and Medical Licensing Boards: Update\nand Report on CAC Survey, March 1992, and Information &change Between Peer Review\nOrganizations and Medical Licensing Boards: Report on the 50 State Survey, November\n1992.)\n\n 5 Other OIG reports include: The Utilization and Quality Control Peer Review\nOrganization Program: Quality Review Activities, OAI-01-00570, September 1988; The\nUtilization and Quality Control Peer Review Organization Program: Sanction Activities,\nOAI-01-00571, November 1988; The Utilization and Quality Control Peer Review\nOrganization Program: An Exploration of Program Electiveness, OAI-01-88-00572,\nFebruary 1989; and, Educating Physicians Responsible for Poor Medical Care: A Review\nof the Peer Review Organizations\xe2\x80\x99 EJorts, OEI-01-89-00020, February 1992.\n\nThe Office of Inspector General has also issued a number of reports on DRG validation.\n\n\n A-2\n\x0c APPENDIX B\n\n PROS\xe2\x80\x99 SOURCESFORIDENTIFYING\n CONFIRMED\n QUALITY-\xe2\x80\xa2F-CAmPROBLEMS\n UNDERTHEFOURTHCONTRACT THROUGHJUNE30, 1994\n FORREVIEWSCOMPLETED\n\n\n TYPE OF REVIEw Total Quality AS a percentage\n\n Problems Identified Of All Quality Problems\n\n RANDOMSAMPLE\xe2\x80\x9d\n 4261 70.9%\n REVIEWSh\n MANDATORY\n 519 8.6%\n MedicareCodeEditOr 15 <1%\n HospitalAdjustment\n 37 <1%\n Assistant at Cataract Surgery\n\n o 0%\n Fiscal Intermediary (FI) referral\n\n 88 <1%\n Regional Office (RO) referral\n\n 4 <1%\n Hospital Issued Notice of Noncoverage\n 274 4.6%\n Beneficiary ComPIaint\n 101 1.7%\n MlSCELL~Ous REVIEWISC\n 1438 23.9%\n Other\n 329 <1%\n Intervening Care\n 29 <1%\n Focussed Review Selection\n\n 11 <1%\n PRO-selected Intensified review\n\n 5 <1%\n FI/Carrier Pre-payment Reject\n\n 3 <1%\n Ventilator-Dependent Unit\n\n 1 <1%\n FI Prepayment Reject\n\n 3 <1%\n Readmission\n\n 527 8.8%\n Specialty Hospita]\n\n 355 5.9%\n UCDS\n ..=\n 168 2.8%\n Hospital Adjustment Previously selected\n\n 7 <1%\n TOTALS\n 6218d 103.5%\nNotes:\t N =53 PROS. The number of beneficiary complaints represented here should be considered conservative\n because of reporting flaws. Ten PROS reported no beneficiary complaink when in fact they received\n such complaints under the fourth contract.\n \xe2\x80\x9c Will be eliminated as of October 1995. ~ Will continue as\n the main source of record reviews.\n c Of the types of reviews listed here, only the \xe2\x80\x9cother\xe2\x80\x9d category and\n the hospital adjustment previously selected are likely to be continued. J Of these quality-of-care\n problems, 208 were selected for more than 1 reason. The PROS identified 6010 confirmed qualiV-of\xc2\xad\n care problems through June 31, 1994.\nSource: HCFAPROD3andPROD5databases. Analysis:HHSOfficeof inspectorGeneral.\n\n\n\n B-1\n\n\x0c APPENDIX C\n\n\n INTERVENTIONS\n INCLUDEDIN IMPROVEMEm PLANS\n\n\n Directed to Directed to Total\n Intervention Physicians Hospitals (n=53)\n (n=25) (n=28)\n Protocol/Policy Change\n 5 (20%) 22 (79%) 27 (53%)\n Inservice Training\n 5 (20%) 17 (61%) 22 (42%)\n Continuing Medical Education (CME)\n 8 (32%) .- 8 (15%)\n Case Presentation\n 4 (16%) 8 (29%) 12 (23%)\n Hospital Case Monitoring\n 4 (16%) 12 (43%) 16 (30%)\n PRO Case Monitoring\n 2 (8%) 1 (4%) 3 (6%)\n Meeting with the Hospital\n 5 (20%) 8 (29%) 13 (25%)\n Meeting with the PRO\n 6 (24%) 3 (11%) 9 (17%)\n Referral to Hospital\n\n Quality Assurance Committee\n\n 7 (28%) 10 (36%) 17 (32%)\n Required Consultation\n\n 3 (12%) -- 3 (6%)\n $PEX Exam\n\n 1 (4%) -- 1 (2%)\n consideration of Sanction\n\n 9 (36%) 4 (14%) 13 (25%)\n I_\xe2\x80\x99elephoneCall\n\n 2 (8%) 1 (4%) 3 (6%)\n )ther\n\n 3 (12%) -. 3 (6%)\n ote: Our analysis was based on those written materials (mostly letters) sent to us by the PROS. Thus, any telephone calls, meetings, or\n other irrtmwtdons IIOt documented in tfrese written materials are excluded from this table. These represent 53 of tile 146\n improvement plans that PROS in our sample initiated under the fourtfr ecmtract.\n\n nsrce: HHS Office of Inspector General Survey of 22 PROS, January 1995.\n\n.4rsal@.s: HHS Office of Inspector General.\n\n\n\n\n c-1\n\x0c TYPOLOGYOF INI\xe2\x80\x99ERVENTIONS\n USEDIN IMPROVEMENT\n PLANS\n\n\nII Typology I Interventions directed to I Interventions directed to II\n1! Physicians (n=25) Hospitals (n=28)\n I\n Educational 15 (60%) 17 (60%)\n Systemic 5 (20%) 22 (79%)\n Punitive 9 (36%) 4 (14%)\n Note Thser~r@ent 460ftie 146improvement plmtiat PROsinour smpleinitiati under tie foufimntract. Ouramdysis was basedon\n those wrhtcnrnatcrials(m ostiyle tters)se nttousbyrhePROs. Thus, arryklephoneealls, meetings, orother interviews mrtdocumented inrfrese\n written msterials are excludedfromthk table.\n\n The number of interventions we identified in any one improvement plan ranged from one to seven. Depending on the interventions wittdn any one\n improvement plan, it could be characterized as educational, systemic, punitive, or a combination of these. Five of the plans dbccted to physicians\n and two direettsf to hospitals contained no interventions we considered educational, systemic, or punitive.\n\n\n We considered the following interventions aa educational: ioserviw training, continuing education, and case presentations. We considered\n interventions as systemic if they involved protocol and policy changes, including the use of new forms and posting of rules. We considered\n interventions as punitive if they involved consideration of sanction, We excluded interventions such aa meetings and monitoring because we were\n unable to determine whether they were edrscatiomd or punitive in nature.\n\nIIsource HHS Office of Inspector General Survey of 22 PROS, January 1995,\n II\n Analysis: HHS Office of Inspector General.\n\n\n\n\n c-2\n\x0c APPENDIX D\n\n\nOVERVIEWOF SANCTIONDATAFROMTHEOFFICEOF INSPECTOR\n GENERAL(OIG)\n\n\n PRO SANCTION\n RECOMMENDATIONS\n TO THEOIG BY TYPEOF PROVIDER\n\n\n Type of FY FY FY FY FY FY FY FY FY\n Provider: 86 87 88 89 90 91 92 93 94 TOTAL\nPhysician 60 66 34 21 29 12 13 12 13 260\n Hospital 6 6 3 1 0 0 1 0 0 17\n Nursing\n Home o 0 0 0 0 0 0 1 0 1\n\n Total 66 72 37 22 29 12 14 13 13 278\nSource HHSOffice of Inspector General, Office of Investigations.\n\n\n\n OIG SANCTIONS\n BASEDON PRO RECOMMENDATIONS\n BY TYPEOF SANCTION\n\n\n Type of FY FY FY FY FY FY FY FY FY\n Sanction 86 87 88 89 90 91 92 93 94 TOTAL\n Exclusion 21 34 18 10 13 10 5 7 7 125\n Monetary\n Penalty 9 16 2 0 0 0 1 0 0 28\n *Pre-\nExclusion 0 0 2 1 1 2 0 3 0 9\nRetirement\n Total 30 50 22 11 14 12 6 10 7 162\nSource HHSOffIce of Inspeetor General, Office of Investigations.\n\n\xe2\x80\x98Pre-exclus ion retirement results from an agreement among the PRO, the physician, and tbe OIG that the physician retire from practice rather\nthan be excluded. Because the retirement would not have occurred witbout tbe saoction reeommendation, the OIG counts these as aetioos taken.\n\n\n\n\n D-1\n\n\x0c REFERRALSREJECTEDOR CLOSEDBY THEOIG WITHOUTSANCTION\n \xe2\x80\x94\n Rejection FY FY FY FY FY FY FY FY FY\n Based on: 86 87 88 89 90 91 92 93 94 TOTAL\n \xe2\x80\x94\n Unwilling\n or Unable\n Require- 0 19 11 4 4 2 2 1 0 43\n ment\nFailure to\n Follow\nRegulatory 4 10 12 6 2 1 0 1 1 37\n Process\n Lack of\n Medical 6 5 0 2 2 5 7 1 1 29\n Evidence\n \xe2\x80\x94 -\nClosed Due\nto Death or 2 0 0 0 0 0 0 0 3 5\n Other\n Total 12 34 23 12 8 8 9 3 5 114\nSource HHSOffice of Inspector General, Office of Investigations.\n\n\n\n\n D-2\n\n\x0c APPENDIX E\n\n\n Conmimrs oN mm DRAFT IWPORT\n\nInthis appendix, represent in fill thecoments from the Health Care Financing\nAdministration, the American Medical Peer Review Association, the American Medical\nAssociation, theherican Association of Retired Persons, the Public Citizen Health\nResearch Group, andthe Coalition for Consumer Protection and Quality in Healti Care\nReform.\n\n\n\n\n E-1\n\n\x0c ..\n ...!{.,\n\n .. ~\n ,.. 1.\n\n\n:\n \xe2\x80\x9cJg\n---\n:.\n -.,\n .\xe2\x80\x99\n \xe2\x80\x98+\n \xe2\x80\x98-d,\n > \xe2\x80\x9d\n DEP.4RT31ENTOF HE.ALTH & HUNIAN SERVICES Health Care Financing Administratic\n\n\n\n Office of the Administrator\n Washington, D.C. 20201\n\n\n\n\n .\n\n\n DATE: OCT25 D%\n\n TO: June Gibbs Brown\n Inspector General .\n .&\n FROM: Bruce C. Vladecl$\n Administrator w-\n\n SUBJECT\t Office of Inspector General Drti Report: \xe2\x80\x9cThe Medicare Peer Review\n Organizations\xe2\x80\x99 (PROS) Role in Identi&ing and Responding to Poor\n Performances,\xe2\x80\x9d (OEI-O 1-93-00251)\n\n We reviewed the subject draft report which examines how well the PROS are finding\n and taking action on poorly performing physicians and hospitals.\n\n Our detailed comments are attached for your consideration.\n\n Thank you for the opportunity to review and cornrnent on this report. Please contact\n us if you would like to discuss our comments Ii.rther.\n\n Attachment ~\n\x0c Health Care Financing Administration (HCFA) Comments\n on Office of Insuector General (OIG) Draft Re~ort:\n \xe2\x80\x9cT\xe2\x80\x99he Medicare Peer Review Organizations\xe2\x80\x99 (PROS) Role\n in\t Identifying and Resuondin~ to Poor\n Performers,\xe2\x80\x9d (OEI-01-93-00251)\n\n\n\nOIG Recommendation\n\nHCFA should reconsider the PROS\xe2\x80\x99 fiction to identi& and respond effectively to\npoor performing physicians and hospitals. Two options are offered.\n\n OPTION 1\n\n The HCFA should proceed toward directing the PROS to focus exclusively on\n improving the mainstream of care. To help deal with poor performers, it should\n consider ways in which the Federal Govemxnent might support other bodies,\n such as State medical boards and ombudsmen, that are more focused on\n addressing individual cases of poor medical care.\n\n OPTION 2\n\n The HCFA should devote further inquiry to determine:\n\n (1) if the two functions of improving the mainstream of care and identi~ing and\n\n dealing effectively with poor performers can reasonably be performed by one\n\n organization. and (2) how PROS can carry out both simultaneously. Toward\n\n this end, it could support research efforts, demonstration projects by individual\n\n PROS, and conferences.\n\n\nHCFA Resuonse\n\nHCFA concurs and believes that both options have merit. We will work with our\nresources and the medical community to explore avenues to detelmine what processes\nare best to deal with the types of poor performers mentioned in this report.\n\nTechnical/General Comments\n\n1.\t We suggest that the following language be added to introduce the hvo options\n offered in your recommendation: \xe2\x80\x9cThere needs to be a public discussion on\n what existing or potential process there could be for dealing with the types\n of poor performers mentioned in this report. Here are hvo options. \xe2\x80\x9d\n\x0cPage 2\n\n\n2.\n In regard to your discussion of Limited Analysis on page 4, we wish to point\n out that the PROS have the authority and opportunity to perform primary data\n collection if they find an instance of questionable care. We have asked PROS to\n take a scientific approach in investigating such cases through the analysis of\n clinical and operational records associated with the performance at issue.\n\n3.\t In regard to your discussion on Weakened Protections, we question why the\n emphasis is placed on the 50 percent of PROS that fmd protections weakened\n which apparently argues that the case review approach is better. We do not\n believe it is the OIGS intention to present an argument for case review;\n however, a reader could infer this based on the way survey results are discussed\n in this report.\n\n We thus suggest that the OIG clari~ their survey results to ensure that the\n reader understands that the OIG is not advocating case review. We recommend\n the following language: \xe2\x80\x9cForty-one percent of the su.meyed PROS felt that\n beneficiary protections are better or equal, 9 percent felt they were neutral, and\n 50 percent felt that the protections are weaker. \xe2\x80\x9d .M this point tie OIG could\n explain why the case retiew method was prefemed by some PROS and why they\n felt it offered better beneficiary protection.\n\x0c Nil??ii AMERICAN MEDICAL PEER REVIEW ASSOCIATION\n 1140 Connecticut Avwiw, NW . Suite 1050 \xef\xbf\xbd Washington, D.C. 20036 \xef\xbf\xbd 202/331-5790 \xef\xbf\xbd FAX: (202) 833-2047\n\n\n\n\n October 15, 1995\n\n\n June Gibbs Brown\n\n Inspector General\n\n Department of Health & Human Services\n\n OffIce of Inspector General\n\n 330 Independence Avenue, S.W.\n\n Washington, D.C. 20201\n\n\nDear Ms. Brown:\n\n\nOn behalf of the American Medical Peer Review Association (AMPRA) -- the national\nmembership association representing the nation\xe2\x80\x99s network of peer review organizations -- I\nappreciate the opportunity to review the draft Inspector General\xe2\x80\x99s report, \xe2\x80\x9cThe Medicare Peer\nReview Organization\xe2\x80\x99s Role in Identl~ing and Responding to Poor Performers. \xe2\x80\x9d\n\nAMPR4 favors option two:\n\n The HCFA should devote further inquiry to determine: (1) f the two functions of\n improving the mainstream of care and identlfiing and dealing e~ectively with poor\n performers can reasonably be performed by one organization, and (2) how PROS can\n carry out both simultaneously. Toward this end, it could support research eflorts,\n demonstration projects b,v individual PROS, and conference.\n\nIt is premature to focus PRO activity exclusively on improving the mainstream of care until\nwe have further evaluated the Health Care Quality Improvement Program\xe2\x80\x99s (HCQIP) ability\nto deal with poor performance. In principle, we believe that the two functions are compatible.\n\nAMPR+ maintains that individual case review is not the only means to identify and to respond\nto poor performers. The innovative HCQIP approach of anaiysis and feedback of patterns of\ncare, through the comparison of provider performance to scientifically based quality measures,\nshows promise for evaluating the full range of practice performance includirw those providers\non the tail end of the performance distribution. While the emphasis is on improving the\nmainstream of care. PROS are also responsible for holding providers accountable for\nimprovement, particularly those providers whose performance show great variance from\naccepted quality standards and are unwilling or unable to correct identified quality concerns.\nWithout PRO sanction and corrective action authority, there is a real question as to whether\nall providers will be committed to making quality improvement a priority.\n\x0c The Medicare PRO k Role in Identlfiing and Responding to Poor Pe~ormers comments continued\n --\n October 15, 1995\n\n Page 2\n\n\n While still early in HCQIP\xe2\x80\x99s evolution, there are, nonetheless, many exampies which\nsuccessfully identify and deal with poor performance. For example, unnecessary radical\nprostate cancer surgery for men over the age of 70 represents poor practice that has been\ncorrected by PROS through feedback of information to doctors on the rates of surgety for older\nmen together with the scientific evidence for non-surgical intervention. Recent guidelines by\nthe American College of Cardiology and the American Heart Association state that routine\nright heart catheterization is unnecessary. As a result of PRO performance monitoring,\nfeedback, and education, right heart catheterization rates have dropped significantly.\n\nAdditionally, in Florid% Medicare beneficiaries were denied cataract surgery because of\nrestrictive criteria employed by Medicare HMOS at variance from accepted Agency for Health\nCare Policy and Research (AHCPR) guidelines. PRO intervention led the HMOS to adopt the\nAHCPR guidelines, and beneficiaries now enjoy increased access to necessary care. .4MIR4\ncontends that HCQIP\xe2\x80\x99s more scientific and systems-oriented approach to identifying and\nresponding to poor performers might prove to be a more effective strategy than the subjective\nand highly litigious system of individual case review.\n\nThere are other reasons why AMPRA supports option two: 1) PROS are still engaged in\nindividual case review through review of beneficiary complaints and hospital notices of non-\ncoverage; 2) the absence of sanction authority would weaken the PROS\xe2\x80\x99 authority with the\nmedical community (as observed in the report); and, 3) removing the sanction authority from\nPROS would endanger beneficiaries if other mechanisms fail to effectively deal with poor\nperformers.\n\nAMPRA also recommends that PRO interaction and communications with state medical boards,\nombudsmen, licensing agencies, and accrediting bodies be strengthened. We urge HCFA to\nissue regulations that would implement the 1993 statute that requires the sharing of information\nbetween PROS and medical licensing boards.\n\nJust recently AMPR4 and Joint Commission on the Accreditation of Healthcare Organizations\ncollaborated on a pilot project in the state of Pennsylvania to share PRO and joint Commission\nhospital accreditation findings for the purpose of accelerating hospital improvement activities.\nVoluntary efforts at information sharing such as this should be encouraged.\n\nAgain, we thank you for allowing us the opportunity to comment. Please let us know how we\ncan be of further assistance in resolving these important public policy issues.\n\nS~cerely,\n\n\n\n\n)3xecutive Vice President\n\x0c American lNledical\n Association\n Physlclansdedicacedto the health of Anerlca\n\n\n\n JamesS.Todd,.M1 515North State Street 312464-5000\n ExecutiveVice President ChiCagO,Illinois 60610 312464-4184 Fax\n\n October 13, 1995\n\n June Gibbs Brown\n\n Inspector General\n\n Department of Health and Human Services\n\n 330 Independence Avenue, S.W. Room 5250\n\n Washington, D.C. 20201\n\n\n Dear Ms. Brown,\n\n The American Medical Association (AMA) appreciates the opportunity to respond to the\n\n recommendations contained in [he Office of Inspector General (OIG) report, The Medicare Peer\n\n Review Organizations\xe2\x80\x99 Role In Identifvirw and ResDondin~ to Poor Performers.\n\n\n During the past two years, there has been a positive reaction from the medical community in\n\n response to the PRO program, specifically the PRO Fourth Scope of Work. The PRO Fourth\n\n Scope of Work correctly and appropriately attempts to improve the overaII quality of are\n\n provided to Medicare patients by analyzing patterns of care and outcomes and by sharing\n\n information with the medical community. In placing a greater emphasis on physician and\n\n provider education, there has been an increased level of collaboration among PROS, hospitals, and\n\n physicians on quality improvement efforts.\n\n\nWe are pleased that the new Fifth Scope of Work, which will continue to define the future\n\ndirection of the PRO program, builds on the positive changes of the current scope of work by\n\nfurther enhancing these cooperative activities. The AMA remains very supportive of the\n\neducational, non-punitive direction of the Medicare PRO program. We continue to believe that\n\nthe program\xe2\x80\x99s emphasis should be on improving the mainstream of care through pattern anaiysis\n\nrather than a punitive approach that addresses individual clinical errors.\n\n\nToward [his end, we have no firm position on the two specific recommended options f~r the PRO\n\nprogram as discussed in this report. Given your assumption, with which we wholeheartedly\n\nconcur. [hat [he PRO program\xe2\x80\x99s primary focus should be on improving the mainstream of care,\n\nwe believe [ha[, if [he Health Care Financing Administration ~HCFA) determines that i~entifying\n\nand responding to poor performers should remain a funccion of the PRO program, further study is\n\nappropriate to determine the potential effectiveness of PROS in performing both activities.\n\nRegardless of the actions taken, HCFA must take great care not to undercut the educational\n\napproach of the current PRO program, as well as the improving cooperative relationship? between\n\nthe PROS and the medical community.\n\n\nAgain, [hank vou for the opportunity to cornrnem on this report. The AMA is strongij committed\n\nto [he objec[ive of maintaining, and, where needed, improving [he quality of care provided to\n\n!vIedicarepatients and will continue to play an active role in ensuring that physicians\xe2\x80\x9d ~:rspectives\n\nare an integral part of the PRO process.\n\n\nSincerely,\n\n\n ~ d. %5@ m)a\nt ames S. Todd, MD\n\x0c OJ\xe2\x80\x99i*l@fintu #*\xe2\x80\x9dcnu/lad soJB?\xe2\x80\x99w R&&acwium\n ku&tY&jl\n November 21, 1995\n\n\n\n\n JuneQibbs Brow-n\n Illspomr\n\n General\n\n Dqmtmcmt of EIedth and Humm S-\n Officoofthc Inapcmr Ocaeral\n 330 Indoperidenee Avenue, S.W.\n WmhhgtOS D,C. 20201\n\n Dear IilspOctofGenwld Browlx\n\n TheAmcrieanAssociationofliotimd PcrsoLIs\n (AARP)appnxiatca& Wp=nu@\xe2\x80\x99mooxz$=m\n on the ifxpoxtantdraftnqxm \xe2\x80\x9cTheMsdbrc pm Rdtmu Ckgmizaticma\xe2\x80\x99RoJeh ~\n andRespondingto Poor I%zf&mers,\xe2\x80\x9d\n\nYOUsu~gesedudHCFAreconsider PROS\xe2\x80\x99lkuedonandeilhr directthe PROSto Ibous\n-u$ivdya~mtk~~of~,~~m~=d\nhow quality ~t@paibtprotection\n \xe2\x80\x9c f&noticms\n cimreusonabIybeperfoxmodbyanc\norgan@don.\n\nWe do not concur with M fm option becauseAARPbelievess?xon@ychatPROSshould\nmain the msponsibilhy to idend@ sad respond cffkodvelyto poor~ pcrftmntng @yatcians\nand hospitals. To do S0,@c~tierkt pmtim demears ahmddbe StIUI@WBdSOthSt they\ncan be ellkcfive. In addition, t&equality _vcanant functionsPROShavs assumedshould\nbe evaluatedto assess their impacton patientwel!-being.\n\n . .\nJhckpmund an~\n\nAs AHlatest draft report ixxiicatw, #e PROpmgnun bm undergonea pmfd uadbmmth\ndwhg tk lastsevwd yems, fkomme fwwed primsriiy on ident@ing tu%iaddressing\nindividual k4aneos of pvor wireto ORScmpbaaizingthe overallhuprovameQcof mm through\ncooperative+quality improvermmprojscts. The transformationwas sat h motion by W 1990\nInstitute of Medicinerqwrton Mediearequdiq assurance, endbaaptied ~ @ atcoq\nSuppott of thehealthpolicy andprovklercommwmies.\n\n\n\n\n Anm4cm ~0~ of~~r~ P=$u 601E SUCC% N.W., Wmbin&oIt, D,c. 2004-9 (202) 43+-2277\n EUgQIUt. bkIHIJh .?%\xe2\x80\x99i&a/ Hence B, Deem &Jmdvt Dimnw\n .-.\n Y.\n \\ .-.\n\x0c Inspeetor Chard BrowrA\n Novmabcr 21,1995\n Page 2\n\n f)lUiII$Sk dcbatoa~ ~d the tGUISfOIIX\xe2\x80\x99IatiOIL\n ~\n ~ &WftO.@On of\n (CQD principlesand methoddogiea ho SheFRO-hoapiwd\xc2\xad\n \xe2\x80\x9cContimIonsQuality,Iinp.rovemcmt\xe2\x80\x9d\n\n phpn Mcx@on. At the sanwdine,h~er, tie Aamei@on - CM Mdibuc\n padems\xe2\x80\x99imcmatarequirednxaion of PROS\xe2\x80\x99capab~ coaddmmidividual poor\n .\n perbmmmand mentkx&\n poorpe@rm!m ti3rougltvi@rou$iute\n\n OIG\xe2\x80\x99s drafkreportdocummtsthefollo-.\n\n 1.\t w*&pti~mofa{d m@mvbw, mo*tim*d~h\n - ofdermting ktancea ofpoorcaxe. Rcoonireviow ad da~colktionhad beers the\n PRO tool tkt idaniilkd 71 perccmofquaLity\n problcmainrhe pt.\n\n 2. Thenew climateof coopemdonwkhthephysiciawhoaphal ~v~bY\xc2\xad\n \xe2\x80\x9cCQI*approach,whileadmirable,appedrato havetakensomermthm of sherole of PRO\n aawatchdog. l?ilra~PROaate idcm@ingveryf- qualityproblems. SeeoT&PR@ are\n MfoMo~~onti~ @i_ bWOIG~d Z~~, oflti@@\n problemsidentified,SOpercentwm hatulkdby OIXPRO, andPRO action on quality\n\n problems\nfor the most part waa a letter of cautioxL Third, shore is no evideave tha follow\n UP ISnow beh~ handled by hoepitals, Fihdiy, it appeamjhxn OIG\xe2\x80\x99Sfludingg chatPRCh\n arenot sharinginformationon qwdicyof careraseawjthstarelieendng boardsaJrequhd.\n\n\n\n\nQ Esmbliahmemof a homca.1dischargeappealsya@mthat embl~ paticauKO requesta PRO\n reviewof a deciiion to terminateMedicare of a hospital stay.\n covernge\n\n\n\xef\xbf\xbd\t Thebeneficiaryc~mplaintauthority,whichenabltabeueiiciadeato obtain a PRO rcvkw of\n an We$ation of ii quality of care probkrn.\n\n\xef\xbf\xbd The oYerail PRO xcview authoritythat was pmnously implomenrfd through ramiom eaat!\n rcvkw aimed at txncove~ quality and uWrarbn conccrxKLbus whioh now utilizes paltern\n tiysis k the puxmit of IItainatream quality improv~.\n\nIn resporuiklg to the dl-llfirel)orc\xe2\x80\x99srecommdatl \xe2\x80\x98on, we believe it should bo evaluated in the\ncomtext of all the padeut promxkmtllnctions ourlked above,\n\x0c InspectilrGeneml Brown\n Novomber 21,1995\n Page 3\n\n\n\n\nW&ile not the su@ct of the draft report, the PROs\xe2\x80\x99statutoryresponsibilityto respond to\nMedicare beneficiaries\xe2\x80\x99~ for rdew of a hospitaldiachsrgc_ cO_ 10CmbOdy\naaiqortmtpadempnwctkmmle, Rcoomly,AA RPhaspM patedinab skfore@efbrlto\n improve the Wmrxunlcation of berletiiaxios\xe2\x80\x99 Ciis&qe appeal rights Ihrougb a mwrkhlg Ofthc\n \xe2\x80\x9cImportant Message ftemMedicare\xe2\x80\x9dandtheuseof additionalmdxds, wch asWoos mde\n available to hosphalizod patkma and their fknilies. HCFAshould proceed with\n .\n fmplememat$omtithe task force mmmwdmm , and PRGashould wdeztake to aggmdwly\n informpatienbofthcir dkhergeappudxiglm. \xe2\x80\x98lhcrahasaotbmn,aa dahouldnotbo,any\n conilictbetweenMEPROrole andPROS\xe2\x80\x99newerquafityimpmvememflnmioas.\n\n\n\n01G6 recent companion &sit report on the benefiekry cumplaint anthorip rmmaied Wrimw\noperatlOnai doficiela5es, wbicbMRPaddW#cd iJlitecoxmm?m &t&r of~27, 1995.\nAs we sUNcdin that letter. \xe2\x80\x98In,liglxof theetjminationof randomsamplerecordmviawthe\nprocessof Mm?-@ relqmldiqgto bmll@uy eemp- aasumeaevellgmter\n-ce~ameuti~b~~Mtim~w-~s\n\nTheOIGreportsmakeclearthatcomplaints~ be+ma productivemum of qualityof csre\nconocrn$.Moreover,k ia char thatneitherH@A am the PROSperceiveanh!xxmq@bil.ity\nMrwecnthe eomplaiatautheri~ml the qpalityimprovemeau strategy;~hint inW6@ation\nisaprominem fknureofthefifthsmpeofwork\xe2\x80\x99spadentp nmctiondement% mm AARP\xe2\x80\x99a\n_ve, tie complaintawhor& dcficieaxiesshouldbe remedkl, patimcsshouldk -C\nawareof its exktence, awl PROSshouldcontinueto serveas complaiutixveaiigatars.\n\n3. XJe PR~ v\xe2\x80\x99\n\nPRO-initiatedreview activitypmsmta b greatest pemcived-C between a strategy aimed\nat identi@ii poor pcrfbmwrs, and one aimed at qwdi~ improvement. Clearly, tbe la-\nSua@gyhas~vaik~ and,aathe 01(3 reportobserves:\n\n W& recognizetharthe nzndam nndews were Uor-inrmhg gemrmted much dkcowl\n widl ~hemedictd cornnmnity, anti idenrg?edJ%w@@@+car e problem mhtme rv the\n nundxm ofrecod rew\xe2\x80\x9dewed.We ati undemtundtlurr chepmrn&r qfrhe PRO\n &ogram\xe2\x80\x99s ment dincrion hoiclrpnmd$efor lqrvving #u overallpmcrice of\n medicine, 7hi.ris @great impo~e to Medicare hnej?duia and others. \xe2\x80\x9d\n\x0c Iaspectur Gened Brown\n Nowubcr21, 1995\n *4\n\n\n lthMbm W~on&Msee bMba CQTwiew-wtiqq\n patiti~~- ~over~~m~ti p~, dtie~~\n individualmlaRaxl Ofpoorqueli!yWiutin boaddxcosed- sciplinary\n cdlxationalordi\n responsesas rcquhvd. 10thismnuecli~ animeresdngfioding&t& (XG mndyis that77\n percentof* PROSquerild(17 outVfz) boliew lhatthetwo no fimdims areCOmpadble.\n Atthosametime, however,halfthinkbencficiarypmectimshave bomwebytie\n cwrentscope of work.\n\n Fm~tij~ontie sWti&ews~Wistiti Tloncwatraegy isapmmidng\n one, but remaius ~V~tdktOimSOf~l~~~Qn~~~. we-\n OIGto~e~&witi~to timm Arc~dfi RWk~W\n IknprovexxxxProgram We alao, as duted above, -b the importanceof viewingWtOa\xe2\x80\x99\n patient protection role in a broader comextthaxincludesrhe disobargeappeab awl bencf!eiary\n comphi.imelomenrs. Curren@, those eknems exist Iargclyas \xe2\x80\x9cpaper\xe2\x80\x9dfimctbs, and require\n extensive pubkity and opemtimal @rovemmm coenable than to serve padonta adquarely.\n\n pk~S WXMili tk ItUIjOr\n lYStiOOd\n\n ~@Wri Wtfh SU@O\xe2\x80\x99dy tt)iUtWVIXW ~ khdf Df MUii~\n\n beneficiariesandfleet theirqualityof care, As moreof those bendciarb move into @w\n forms of hedlh cam delivery, with hadal Hvea that possibly tbaten healrh W\n @=W# P*- Pro-M be=me - more CWcal.\n\n Tho OilIce of In9pector General\xe2\x80\x99s ongoing efhta la otYerremedies for aml deficienciesm the\n PRo program cmninue to prwide a great service co Mcdioam &ae&bes \xe2\x80\x9c .Wekmklbrtvd\n to~toworkti you~d~btim mb~ati~~q,\n\n Thank you again for the oppommity to cxxnmcz&If you should have any questions, phxme\n contactM-JO Gibson in AARP\xe2\x80\x99s Public Poticy Jhstituteat (202) 434-3896 or -I\n Matheis in Fcdezal MU\xe2\x80\x99s at (X2) 434-3774,\n\nsincerely,\n\n*&\nVolm\n Rdkr\nDream\n\nLegislation and Public Policy\n\n\x0c .\xe2\x80\x94\n\n\n\n\n October 16, 1995\n\n\n\nJune Gibbs Brown ,\n\nXnspCctorGeacrei\n\nDepamnent of Healthsnd HumanSewic&z\n\nWashington,D.C. 20201\n\n\nDear Ms. Broww\n\n Please find enclosed our comments on the OIG\xe2\x80\x99S draft repo@ \xe2\x80\x9cThe Medicare\nPeerReview or@lJbti021S\xe2\x80\x99 Role in Idmt@ing md kpmdiq to Poor Performers.\xe2\x80\x9d\nWe appreciate the opportunityto review and commenton (his report. Pleam let us\nkuow if we can be of furtherassistanceto you or your staiT in your studies regarding\nP= Review Orgsnimtions.\n\n\n\n\n SkJJiC\n u\nSi&ey\nDirector\n sw fe, M.D. Laureu Dam\n Staff Attorney\n\n\n\n\nEmiosure\n\n\n\n fblph Nadrr, Frnadu\n\x0c co~ ON \xe2\x80\x9c~ MEDICARE p= RE~ ORGA~~ONs*\xe2\x80\x9d\n ROLE 11+1\n IDENTIFWNG AND RESPONDING TO POOR PERFORMERS\xe2\x80\x9d\n (OELOM2-002SI)\n\n Submntcd by Public Citi&n\xe2\x80\x99s HeahhResearchOsoup\n October 16, 1995\n\n Wc qpwiate this oppwtmhytounnment nnthisreport bythe OfTweof I~\n General~OIG\xe2\x80\x9d) ofthc Dep@nwntof HealthandHuman Semoes (WHS\xe2\x80\x9d). Public Citizen\xe2\x80\x99s\n Health Research Group has k a ~ of theeoaceptof P= Reviav organizations\n (\xe2\x80\x9cPROS\xe2\x80\x9d) since their inceptiom end believca that PROS, ifsmq@ex@ could Serve 9 M roje\n in protecting Medicarebeneficimies* P- CPM@ndicai -. A the repofipints ou&\n the main emphasisof PROShas shiftedin the past fw years from ttying to identifi end\n resporxl to imiividtlal phyalc188Sand hospitals that are performing poorly, to incorporating the\n concepts of \xe2\x80\x9ccontinuous quality irnprovcmcrd\xe2\x80\x99! md umrlcing with the medical conmxmity to\n improve the overall quaiity of medicine.\n\n We agree with the report thaG given this shifl in focus, it is hn-t co assess the\n abilky of the PRC)Sw continue to perform tiir \xe2\x80\x9cpolicing\xe2\x80\x9d role. We disagree, hovwwer, with\n the policy options suggested by the rupor% partict+arly Option One \xe2\x80\x93 to eliminate tha PROS\xe2\x80\x99\n role in identi~ and responding to individual poor pcrfimnus, and to focus only on\n improvesmmt in the overall practice of medicine. We \xe2\x80\x9ccontitmow quality improvement\xe2\x80\x9d is\n a vvclcome addition to the methods of protecting Medicare I-ef3ciarie$ it dots not and\n cannot, replace the necCsWy task oftkcting poorperforrnent.fmpruv@ theoverallpmctice\nof mdiciac may ineidesulyidenm some poor perfbrmen,but such is not its prinmy goal.\nandin orderto fully pmtcctMedicare beneikhries. the govemmnt mustcontinueto seek out\nthose docto= and hospitals* cawc needless sufkiog because of I\xe2\x80\x94C= ssary or poor\nquality medical cam At_ thereis no organizationor ageacy b adequatelyprotects\nMedicarebenticiasics orthebroaderpatientpopulationtlom @y porfonningphysiciansand\nhospitals. Whatprotectiondoes exist comes from a vasicty of groupqsuch as state medical\nboards,hospitalqualityamuranwdep~ ~on org=imtio~. md o*m Whi*\nat best offer only a patchworkof protection. Emh grouphas a difRmmmission and focus,\nandeach protcas the mstdicalconsumerto oxdya iimitcd degree.\n\n \xef\xbf\xbd State medkal boards, the fii line of defense against poorly perftmnmg physiciq\nhave a mixed record in protecting the public. Each yesr, PubIic Citizen\xe2\x80\x99s Health Ikearch\nGroup compares the perfonnanoe of the various state medical boards by analyzing the rate at\nwhich doctors are disciplined in each state. We have found an enormous variation among the\ndifkrcnt state licensing boards: in 1994. for \xef\xbf\xbdxampk the Kentucky Medical Board had a rate\nof 9.62 seriow disciplinary actions pcr 1000 doctors. while the Pennsylvania Medical Board\nhad a rate of only 2.04 suiom alinxy actions p= 1000 cioctms ~s, while some state\nboards may offer masnnabk protection to citizens in that slam. other boards discipline sv &W\nphysicians that they offer tiost no w~tion m~\n \xef\xbf\xbd Hrmpitd qua~ ssmrmee departrncnts, another possib~e line of defense against\npoor performance, conduct dtcir bwincss behind a shroud of sscrecy, making it bard to assess\n\x0c the S~ of their cffO~- & Of hcambcz 1993, howcvm, Sevcmy-five pemcnt of the\n hospitals in this country had not reported to the National Praotiti- Data Bank even ona\n adverse action taken against a doctor. Given the wry limited number of reports fihxl by\n hospitals -- _~byi=W- there is reason to quastion whether hospitals are\n acsivaly iddifjhg and responding to poor performingktor~ and to be wnccrnerl about the\n level of protection provided to patirmts.\n\n \xef\xbf\xbdAecmdtiag orgdzatioma that inspecthospitals -- the most impmtant being the\n hint Gxnmission on the Accreditation of HealthutreOrgmizmiona(\xe2\x80\x9cNXHO~ -- offbr little\n to instill coufMenm in the public. LI%O hospital quality assurance -~u, the KWfo\n maintim the results of its inspections in secrecy,andrarely* *cRditatioII to a hospital.\n Public Citizen\xe2\x80\x99s Health Rtaeamh GrotqJhas long &en critical of the faot that the JCAHO, a\n private organizdon dosnbtcd by the indusrty it is supposed to be regulating, has been given\n so large a role in \xe2\x80\x9cpmtcoting\xe2\x80\x9d Medicare beneficiaries from poorly performing hospitals.\n\n Option Onc in this rcporr includes ,& mggcdon that the Hcaltb Care F_ing\nAdministnititm consider ways for the fkxfcraigovernrncmto suppm the efforts of organizations\nthat - tnmc fd on addxcs&g individual caxs of poor cam - this is an idsa rhat we\nsuppoc but notat the cost of PROS\xe2\x80\x99 \xe2\x80\x9cpokingrole.\xe2\x80\x9dEm wirhthecxxsmxe of PROS, the\n~m fm kkntifjhg and respdbg to poorly performing physicianssnd hospitais is hardly\na scamieas web. WithoutPROS,?hcmwill be \xef\xbf\xbdven less prorcction for Mdkarc bcncficiarics.\n\n option TWO~ -g the PROSm dctcsmine & &Y can perform both\nroles atthcsarno~tif m,howbcstodom. Whdewcsupport fiJrther study to\ndetermine ways to improve PRO$ WCJ\n would like to point ow hat most of theprobicms\nidcatificd in this report Imvc been identified bcfm in theseries\nof OIG reportscited in\nFootnote 2. WC thePROS\xe2\x80\x99 shift in fbcus may have exacerbated Wme of their probicntsin\nided@ing and maponding to poor pcdorrncrs, the nattm of tbe probkms has not cbnged.\nTO boom the perfomuuwc of pRO& therefore. w suggest that SOMCof the recommendations\nof ptwious reports be vigorously irnplcmcnte4 ia palticuk\n\n \xe2\x80\x98 HHS shouldpropose legislation requiring PROS to provide case infimnation\n to State mdical boards when PROS have con6rmcd that a ptIysicim is\n responsible for poor ctuality of cam rcsuking in harm to the pet.sent. T%e\n legia&tion pmposcd should resoivc the umfbsion causedby OBRA \xe2\x80\x9990. (PL\n 101-508), which rqukcs \xe2\x80\x9cnotice ad hhg\xe2\x80\x9d ~0= PROS sh~ ~\n information.\n \xef\xbf\xbd\n KHS should seek legislative change that would pcnnit PROS to provide and\n ~ive data from the National Practitioner Dara Bank. (he of the problems\n idcntifld in the report is the diflicuky of a PRO determining whether poor\n behavior is part of a pamn or merdy an isolarcd incident and tuxss to other\n information coilmtd in the National PractitionerDatn Bankwould assist in such\n a&termu@ \xe2\x80\x9con.\n\n 2\n\x0c \xe2\x80\x9c m slmuld sdc ~C@ltiW - to imeasc the amount of JZIOM&U\xe2\x80\x99y\n pemddespexmitted in order to make them a more meanhgM sanctiom Current\n lmv limits monetaty penalties to the amount of the medicdly mmcusuy or\n impmper wrvicc -an amount toosmall tosweasa,nadaquate sanotionor\n\n\n \xef\xbf\xbd W sbotdd * legislation\n to repealthe mquircment that physiciansor\n h+ds Which hWC ViO&d Mldkdrc obli@ions IItlly b S=CtiOllCd only if\n they demonstrate au \xe2\x80\x9cunwillingness or inability\xe2\x80\x9d to comply with Medicare\n obligations. 010 reportssince u iesst 1988 have &mti&xl this \xe2\x80\x9cunwilling or\n unable\xe2\x80\x9d requirement s a major impedimem ro PROS ex=isiug thcii sanction\n referral authority, and havw WcOmmendeddcktion Of this n@re?neIIL\n\n \xef\xbf\xbd HHS should inczeasccducatiomdand outreachcfibrts to inform Mcdicarc\n beneficiaries of the existence and fucdons of PfUls. Bencticisry wmplaints\n will become an even mom importantIsourccof leads f= PROSas the mndom\n sample medical record review is phased OUL\n\n PROS can save a vital role in pmtmdng Mcdicam beneficiaries fm poor quaiity\n~dc~b~hwnotym~ti~loti~t~ OVWti P=tycam PROs\xe2\x80\x99 use\nof their simction authority h- dtidIuL and now with* shift in fww to \xe2\x80\x9ccontimmus quality\n.\n~\xe2\x80\x9c and eduoiatioxu we & that PROS till become ICSS effeotive unieas the\nrcwmmendations made in previous 01(3 repo@ attd repeated here in ous commmts. are\nilnplcmenuxi.\n\n We arc not unmindfui of tho difficulties PROSmay have as their msoumes areshiftcd\nmore and more towards doming their mandate to improve rhe general practice of medicine.\nThis focus, however, cannot replace the ncccsary task of i&ntify@ individual pooK\nperformers physiciansandhospitals- in the medicaificid- T&ctwo approachesdeal\n - both\nwith difIkrentaspects of qwdiryproblcu and no matter how much \xe2\x80\x9ccontinuous quality\n~t\xe2\x80\x9d is abk to raise geneml staurkds of medical c- there will always be pour\nperformers who iqjum individualpatientsandwho must be detected and sanctioned. PRO%\nin order to filly protect Mcdicam t=neficitiex must be strcngthend to perform this set+-.\n\n\n\n\n 3\n\x0c \xe2\x80\x94\n\n\nCoalition for Consumer Protection and Quality in HeaithCare Reform\n 1275 K Street, N.W., Suite 900 Washington,DC 20005\n (202)789-3606 Fax (202)842- 1 I 50\n\n\n\n November\n 6, 1995\n Ma.JuneGibbsErown\n General\n Inapecsor\n ~ ofHealthandHumanSenficea\n Cohen Wilding, Room5250\n 330hv@endeIIwAve.,S.W.\n Washin~ D.C.?lMll\n Ma.Brown:\n Dear\n\n M YOU for asking LheCoalitim for Comer Prote~on and Qua@ m Health Care Reform\n to~em m yourdaft r~, \xe2\x80\x9cW h-f~mc peerReview orxtim\xe2\x80\x9d Role in Identifying\n and\n -am-per farmers.\xe2\x80\x9d\n ~e thlitionis composed of mom @ @ OrgSSI&ItiOIIS witi thc c-on goal of a health\n care system that offers good consmner information, meaningful choice, quality assurance, and public\n acumntabiiity. When we receive a tequest for commem such as yours, we cirmdare the document to our\n ItMMbershipasking for their comments. Depending 0SSthe issue, we may receive one or more\n comments. Forexample,iny~ previ~ report,deaI@wifi Wmpltit haIKU@, four of our member\n organizxions -d. We ~ways ~ OKI\n the -M ~eMS of w meo&N, as we did with the\n above-mentioned report.\n\n Onsome issues, rhe CoaliiOSI as a Whole takes a psition. ne nature of our Coalition is such\n that when we do take a Coalition pogition, each memberdoes not mssarily SWbacribetoevery.s@tic\n recomsnendation, butrather suppona what we say as generally on rarget.\n\n Wheuonly one or two of our members respond to a ~1 for COUMNZIU, we do not usually take a\n fOllrmlpositiou as a Cdida. In the ease of your ~M draft rqfl on identifying and re3p0tMing to\n poor performers, we received only one comment -- fromthe CitizenAdvocacy Center(CAC).The\n COtmneM\n is enclosed,While1cannocstatethatCAC\xe2\x80\x99scommentsrxnt theCoalition\xe2\x80\x99s\n position(since\n so few of our members chose to express a view), I can say &at they am qnite knowledgeable about this\n p~~ ~ q generallyrepresentthev~ewsof mosrCoalhion members.\n Thank to comment.\n you fortheopportunity\n\n Sincerely,\n\n\n\n\n BrianW. Lindberg 1\n ExecutiveDirector\n [IXugcomz.wps]\n\x0c C9mENTs\n en the\n\n J2EPARTMKNT\n\n OF HXALTH AND HUMAN$SRWCZS$\n OFFICB OP INSPECTORGRNERAL\n DRAFT R8PORT\n \xe2\x80\x98The RMJIMcasemar Rwviaw Grgamisationet Role\n *\t Xdhntifpag and Req)ondsn$to Pees Pwfoxuem\xe2\x80\x9d\n hs#u8t, 199s\n\n\n\n\n is a WL%queeuppoxt program\n The Citizen Mvooaoy Centar ((SC)\nfor tml thouelacw of public\n maNbere who eerve on health Oara\nregulatory boards end govern~ngbodlss as representativesOS the\nooxammer Interest, Uhather appointed by govornose to serve on\nregulatory or other health policy boarda or @elected by private\n~ectsr institutionsand agencies to se- on boards or advisory\npanels, public anembers are typfcdly in the minority and are\nu8ually without the reaourceu and teuhrdod support available to\ntheir counterpartsfromprotess~onaland businessoommunit$es. -C\nis a not-for-prof$t501(c)(3) arganimtion oreatsid to serve the\npublZc Sntere8tbyprovid$q research,tsaining, teohxdcde upport,\nand networking oppcxtunit~ee to help public members make their\nwntr$buticm~ informed, affact%ve,and n$gnif%cxmt.\n OnaIof CAC\xe2\x80\x99a networmi (caU6td \xe2\x80\x9cPROIWT\xe2\x80\x9d) is oompomd of the\nbeneficiary members of the Boardta of D~seotogS of the Me44csare\nPeer i?evXa$wOrganisationswhich are the sub$eot of this draft\nreport . From time to tlam, PRONET takes positions on matters of\nparticular interesttu Mediaarabeneficiasiew, whioh inolude OIG\nreporte dealing with the performance@f PROS. In thi.a Xnstance,\nPEd!wErlMS&?t yetspo&en Onthedraft reportthatis thesaa@ject\nof @xe*e ~ts. At ite most racent annual meeting in\nGepWnk, 1995 4n S81t Lake City, Utah, PllONP?f members adopted a\nreeolut~on oalling on CAC to convene a fwzum where PRONETmember8\nwould have an opportunityto review and debata the d$reot$on of\nthe M@icer@ quality oversight program and to develop a \xe2\x80\x9cWhite\nPaper\xe2\x80\x9d on tha @ubject for presentationat the 1996 annual\n\n 1\n\n\x0cmeeting. 1 !fhw, PROmr ts comments on the fhading8 end\nreemmendation8 in the OIG\xe2\x80\x99s draft report w1ll be conta$nmd in\nthat future document. me commentspxeeentedhere regleot the\nviews of CAC*\n\n\n\n The OIG presents two major fhditqp:\n\n 1) Ae tha PRO Program becomes inorees$ngly oommitted to\n improving the overallpraatlce of medicine, Its ability to\n find and take actkn on poorly performingphysiciansand\n hG8pita18 Ls questionable.\n\n 2) \xe2\x80\x98NatBPR@ themselves i!indmuch that iz positive about the\n\n ourmnt direotion of the Program. Sut some tmpralm\n\n rs8e~ations about Atm ~mpact on protectingMedScere\n\n benef$e%ar~esfrom poor performers.\n\n M arriving at finding #1, tha OXG concluded that PROW:\n\n - find\xe2\x80\x99 thamaslvee with very limited leads t~ idantify\n #OOZIY performi~ @\xe2\x80\x99&B~ChXW or hospitals):\n are unl~kely to determinewhether inoidente that are\n brought to their attsntion are $aolat@d Went@, Qr Jmrt19of\n a pattern M quwst~c?nable care;\n\n - sarely do more than inform those responeibla of the\n natureof a quality ag care problem when =na is oonfirmad;\n 0 submit vktually no sanotion Iwwxxmandatione to the OZG\n (the number of sanction mxxxwaendatiozm has deolin.d from a\n high Qf 72 in 1987 to only 13 in 1994):\n XxBfarvary few C86MMJto state boards of medicine, even\n %ough 1993 federalle$ialationrequires them to do sm.\n\n Xn arriving at finding #2, the sMG coneludad that While 27\nof 22 PROIB(77%) believe that the two b8eZo PRO funetione --\nimprovtng the Maimtream Qf care end dealing with poor pexferm6rn\n--are Compatible,59? of these same PROS have concluded that\nbenefieiaxy protwtiorw?have become w~akam.\n\n Having made these two findingu,the OIG sug$eetad to the\nHmalth Care Finmcin$ AdNMni8tratiUn (HCFA) that it has two\noptions for the future. Thewa are:\n\n\n\n\n 2\n\x0c OPTION 1: The HCFA should prooeed toward diroctl~ th@ PR08\n to focus ex4u81vely on improv4ngth mainstreamof Oare.\n TQ help deal with poor per ftmnerw, it \xef\xbf\xbdhould oonsidarways\n in whioh zha Federal governm9nt mdght auppoxt other bodies,\n @JUOh 8S State Madloal boards and ombudsmen,that are more\n f ooused on @8res6ing individualoases of poor meditaal oare.\n\n OPTION 2S The WFA devote furtherinquiryto\n should\n determine: (1) if thefunctiunsof improvingtha\n mm\n m8&netreamof aare and Sdentif yin$ and dealingoffeotivaly\n with poor performer8 can rea~onablybe Per$osmedby one\n oxganAz?xtton, and (2) hw PROS can carry out both\n u~multaneously, Toward that end, At oould support resaczwla\n 6f fort8, damonstra~ion projrectaby i.nd~vidualPROD, and\n\n Oonferanoaar .\n\n\n\n with the FourthScopeof Work\n 13894nnix19 h i993, iiCFA\ndramatically olwnged tha primary funotion of the PROS, Thn PROS*\nnaw assignmentwas to analyzmpatterns of oare and outcomes, and\nEw@!J thie iIagorm@$On W%th tm mad~m~ COIUUUdty. moa aov\xe2\x80\x99ed\naway ftom Aaadividuel\n chart reviuw dmignad to Ment%fy pmr\nperformers, effeotLvely ending their role aa polioanen,em wLth\nwh$ch most PROS nmver seemed comftrtmbae. Organized med$cdmeand\nthe pr@idez ooaununity reactedfavorablyto this Ohange in\ndimotion.\n\n Bven durhg the yeare when PROS devotedmout ot their ensr@y\nto ohsrt ravigw, t?my were regulaxly or ftiaiamd fax doi~ a poor\njob of policing poor performers. They sent very fsW =WJCt$OZt\nrewmmendations to the OXG. Tht$y failedto davelepcoopemtiva\nrelationshipswith boards of nwjdicine, whloh have mom\ndisciplinaryauthor$tyand broader powers to supplementPRO\n8anctionauthority, Very few quality of care cases have lxmn\nreferred by PROS to state madicml boards. PRo$itended to prefw\naduoationalInterventions over 8anct&m30 Even 80, as an earlier\nOIG roport revealed, pm educationalinterwmticms fm-alW\ncon8i#ted of notifying a provider of a mnfirmed quul$ty problem\nand adcinfj the providar tc? dw eomethingabout it.\n\n While theZroperations have now changed under tlm Fourth and\nFifth Work, PROS still\n ScoptiIs of retajxa the legal au12t0~lty and\nthe duty to identify and dsal with poor perfomueru, PROS\ncontinue to reoe$ve oomplainte from beneflciarieaand have tha\nraspcxwibilttyfor addressingany qualityproblem revealed in\nthese Oompla$nts.\n\n CAC bel%eves that the 01(3 draft rmport accurately8tat0a the\n.Optione presentlybefore HCFa -- 1) to relieve PROE of\nXeeponeibllity fgr dgal&ng with poor performers, or 2} to fi~ a\nway to reconcilethe apparentoonfl~et betweem this\n\n 3\n\x0creeponmibility and tlw PRO*\xe2\x80\x99 pottern analyg$m qual&ty lmp~\nactivitlos.\n CAC reseweu f$nal judgment until PRONBTha* X m\nQEmJ=@@ty to -- - debata the PRO=\xe2\x80\x99 qualsty Pfoteottioll\nrole. Neverth@eea, we will way ~ha+ we +Unk a lot of\nOonvinchg *4! needS tw justtfy oontirwing to sely on PR08to\npolice poor pergcmmra. Given that PROB did an fnadequatejob of\ndealing w$th poor perfozmazs when th$u was one of their majer\nS96m8~&MXitiOS, whet 28 the evidenoethat PROU w4%1 do 8 mom\n~blo j+ ef POliCMMJ welity xblantm now tbt t~e has\nbecomea lesser X?8Bp0n8ibility in the PRO Scepe of Work? It\nwould be 111.Ssl*ad4ng for PROS to hold thwwelves out as part @f a\n?sWety nea but fa$l to ~rovide meaningful protaotion.\n\n\n\n\n 4\n\x0cPRONET Ri590LUT10NS passed at the Citizen Advoaacy (%ntw \xe2\x80\x9cPRON~ Annual\nNleeUng, September 28,1985.\n\n\n\nRESOLUTION REGAR!31NGTHE PRO BENEFICIARY COMPLAINT PROCESS\n\n WE, THE PRONET BENEFICIARYBOARD MEMBERS ASSEMBLEDFOR THE\n1995 CITIZEN ADVOCACY CENTER \xe2\x80\x9cPRONET\xe2\x80\x9dANNUAL MEETING IN SALT lAKE\nCl\xe2\x80\x99W, UTAH ON SEPTEMBER28, 1995, ENACT THE FOLLOWING RESOLUTION IN\nCONCERN THAT A MORE EFFECTIVE AND MORE ACCOUNTABLE QUALllV-\nRELATED COMPIANT PROCESS IS NECESS4RY TO ADEQUATELY PRC?TECT\nMEDICARE BENEFICIARIES:\n\n WHEREAS, the U.S. Departmentof I=k?afthand Human Senkes Office of the\nInspeotorGeneral (01(3) reoentlyrebimed a draftreporta$wsaing the PRO berietldary\ncomplaint prooess and found such complaints to be a rtoh souroe of qualm of care\npmblem$ and oritical to the PROS\xe2\x80\x99 abiiii to protect beneficiariesfrom individual\ninstanow of pow care, and\n\n WHEREAS, mostbeneficiariesare unawareofthe PRO oomphdntprocae6in apita\nof years of outreachaml pubticeducationefforts,and\n\n WHEREAS, majorbarrierato an affectivecomplaintprooess includethe current\nfederal confidentialityrequirementsand the iengthyinvedgatian process,\n\n THEREFORE, BE IT RESOLVEI) THAT the PRONET Members attendingthe\n1995 Cflizen AdvooaoyCenter \xe2\x80\x9cPRONET\xe2\x80\x99 Annual Meeting urge i+CFA to adopt 8fId\nimplement the 0K3\xe2\x80\x99a raoornmendd.ions,\n including:\n\n 1.\t That i4CFAwork withPROS te ident\xe2\x80\x99Hycoat-effective waya to oomwt the\n fbws in the complaintprocessand requirePRO$ to reepondsubstantiity\n to the complainantas wggested by the 01(3 report.\n\n 2.\t That HCFA work Wth the Citizen Advocacy Center and AMPRA\xe2\x80\x99s\n Commurhtions Network to ide~ mat-effective ways to enhance\n Medkare beneficiaries\xe2\x80\x99avvarenesaof PRO$ and the complaintprowss, in\n additionto the fifth Scope of Work oommunioations directivesthat foous\n on Health Care QualityImprovementin-Kiatives.\n\n 3.\t That HCFA streamlinethe complaintproows in order to expedite the\n investigation and rospoma prooessm To that end, PRONET urges HCFA\n to workwiththe CitizenAdvocacyCenterto collectinformationabout how\n otherhealthcare oversight @dkm such aa state Iicerwing boarda,ccmduot\n complaint inve5tigation6.\n\x0cRESOLUTION REGARDING A FORUM TO REVIEW AND DEBATE THE DIRECTION\nOF \xe2\x80\x98THE MEDICARE QUALIIY OVERSIGHT PROGRAM AND 17S IMPACT ON\nMEDICARE BENEFICIARIES\n\n WE THE PRONET BENEFICIARY BOARD MEMBERS ASSEMBLED FOR THE\n1995 CITIZEfNADVOCACY CENTER \xe2\x80\x9cPRONET\xe2\x80\x9dANNUAL MEETING lN SALT LAKE\nCITY, UTAH Ohl SEPTEMBER 28, 1995, ENACT THE FOLLOWING RESOLUTION IN\nCONCERN ABOUT CHANGES !N QUALITY OVERSIGHT BODIES FOR THE\nMEDICARE PROGI%AM:\n\n WHEREAS, there is a questionabout whether the PRO movement in today\xe2\x80\x99s\nclimateof deregulationand majorchangesin the delivefyof healthcare in the Medioare\nprogram(and Medioaid,etc.) has beoomeirrelevantand veetigial,and\n\n WHEREAS,~ \xe2\x80\x98 ae u oonoeptanda strategytirtho assuranceof quality\nowe for Medioarebeneficiarieshas been etfwtively dismantledand the vast machinery\nof that systemuf review, overnight and l~teraotion has been disassembledand its value\ndissipated,and\n\n WHEREAS, there are varyingdeQW6 of imoeptance of these chartge6 by the\nmedkd profedon, researchwmmunity, and Medbwe benefidarb, and\n\n WHEREAS, PRONET has not had the opportunityto date to 8dquately ooneider\nthese varying opinionsand developits own oolleotivepositionon how these ohartgee\neffeot the quafii of heatthcare fromthe Medkare hmficiw)h PWWWVe,\n\n THEREFORE, BE IT RESOLVED THAT the IWONET M8mb9rS attending the\n18!M Citizen Advocacy Center\xe2\x80\x9cPRONET\xe2\x80\x9dAnnualMeetingurgeCAC to 00nvarwa forUtll\nwhere PRONET memberswouldhavean oppmtun\xe2\x80\x9d~to reviewand debate the direction\nof the Medkare quaiii oversight program.\n\n BE fT FURTHER RESOLVED THAT this recommendationshould be given the\nhighestpriority$0 that the PRONET SteeringCommitteecan develop a \xe2\x80\x9cWhite Paper\xe2\x80\x9d\nthat reflectsthe colleotiiethinkingof the PRONET mernbwshipto be pnmentedduring\nthe 1906 Citizen AdvocaoyCenterAnnualMeeting.\n\nRESOLUTION REQAR9NW THE tICFA CONTRACT BIDDING PROCESS\n\n WE, THE PRONET BENEFICIARYBOARI) MEMBERS ASSEMBLED FOR THE\n1995 CITIZEN ADVOCACY CENTER PRONET ANNUAL MEETING IN SALT LAKE\nCITY, UTAH ON SEPTEMBER 28, 1995, ENACT THE FOLLOVViNGRESOLUTION:\n\n BE IT RESOLVED THAT the PRON~ Mernbwe attending the 1$95 Cit&en\nAdvooacy Center PRONET Annual Meeting u~e the Health Care Financing\nAdministration(I+CFA)to reassessitsrule~governingthe PRO contractbiddingprcxwm\nfor designatinga PRO ina Sivenstateto assurerrwixlnwmfairnessand aquai application\n\x0c APPENDIX F\n\n\n NOTES\n\n\n1. The Institute of Medicine, Medicare: A Strategy for Qualizy Assurance (Washington,\nD. C.: National Academy Press, 1990).\n\n2.\t U.S. Department of Health and Human Services, Office of Inspector General, The\nUtilization and Quality Control Peer Review Organization Program: Qualip Review\nActivities, OAI-01-O0570, September 1988; The Utilization and Quality Control Peer\nReview Organization Program: Sanction Activities, OAI-01-88-00571, November 1988;\nThe Utilization and QualiV Control Peer Review Organization Program: An Exploration\nof Program Effectiveness, OAI-01 -88-00572, February 1989; Educating Physicians\nResponsible for Poor Medical Care: A Review of the Peer Review Organizations\xe2\x80\x99 E#orts,\nOEI-01-89-00020, February 1992; Peer Review Organizations and State Medical Boards:\nA Vital Link, OEI-01-92-00530, April 1993; The Sanction Referral Authori@ of Peer\nReview Organizations, OEI-01-92-00250, April 1993; and The Beneficiary Complaint\nProcess of the Medicare Peer Review Organizations, Draft Report, OEI-01-93-00250,\nJune 1995.\n\nThe Office of Inspector General has also issued a number of reports on DRG validation.\n\n3. Reflects reviews completed under the fourth contracts. The HCFA staggers the\nstarting dates of the PROS\xe2\x80\x99 contracts, thus some PROS began their fourth contract in\nApril 1993, some in July 1993, and some in October 1993.\n\n4.\t The volume of random sample medical record reviews has historically been so large\nthat even with such a low confirmation rate, the majority of quality-of-care problems\nstemmed from those reviews.\n\n5. Hebbel and McMullan to Executive Directors, Peer Review Organizations,\n20 December 1994, Health Care Financing Administration, Baltimore, MD.\n\n6.\t Other than beneficiary complaints, PROS are mandated to review the following types\nof cases: Assistant at Cataract Surgery, Medicare Code Editor, Hospital Adjustment, FI\nreferral, RO referral, and Hospital Issued Notice of Noncoverage (HINN). The PROS\nwill also continue to do some miscellaneous reviews. However, the most fruitful source\namong the miscellaneous reviews--the readmission reviews, which accounted for\n9 percent of the 6,010 confirmed quality-of-care problems that PROS identified--will also\nbe eliminated.\n\n7. The Beneficiary Complaint Process of the Medicare Peer Review Organizations.\n\n8. Those who offered an estimate reported having received one or two or a few such\nreferrals.\n\n\n F-1\n\x0c9. Those whooffered anestimate repofied having received between one and four\nreferrals from hospitals. Nine of those who offered an estimate on physician referrals\nreported having received either a small number or between 1 and 4 such referrals;\n1 reported having received 6; and 2, 10 or more.\n\n10. We understand that PROS, through their HCQIP cooperative projects with hospitals,\ncould identi~ instances of poor performance. However, unless the questionable care is so\negregious as to prompt a sanction recommendation, it will be excluded from the historical\ndata bases of quality-of-care problems that PROS monitor for patterns to emerge.\n\n11. As required in their contracts, the PROS also profile quarterly all the quality-of-care\nproblems they have identified. This activity does not involve reviewing additional case\nrecords on a particular provider but is simply a method for monitoring the PROS\xe2\x80\x99 pool of\nquality-of-care problems to identify patterns of poor care.\n\n12. In determining whether an individual quality-of-care problem would result in an\nimprovement plan, the PROS considered the existence of a pattern of quality-of-care\nconcerns or problems and severity of the problem/harm to the patient. Some PROS\nreported also having considered whether the problem could be corrected, the receptivity of\nthe physician or hospital involved, and the opinion of the medical director.\n\n13. U.S. Department of Health and Human Services, Office of Inspector General,\nHospital Reporting to the National Practitioner Data Bank, OEI-01-94-00050, February\n1995.\n\n14. The National Practitioner Data Bank, established in the Health Care Quality\nImprovement Act of 1986, maintains records of medical malpractice and adverse actions\ntaken by hospitals, other health care entities, licensure boards, and professional societies\nagainst licensed health care professionals. Hospitals and other health care entities must\nreport to the Data Bank all adverse actions they take that affect a practitioner\xe2\x80\x99s clinical\nprivileges for more than 30 days.\n\n15. We reported that the unwilling and unable requirement remained an obstacle despite\nthe Administrative Conference of the United States referring to it as an \xe2\x80\x9cinappropriate\xe2\x80\x9d\nburden of proof in 1989 and Congress\xe2\x80\x99 attempt to make it more workable in the Omnibus\nBudget Reconciliation Act of 1990 (P.L. 101-508).\n\nThe PROS cited the high costs, the complexity of balancing physicians\xe2\x80\x99 rights to due\nprocess with the beneficiaries\xe2\x80\x99 need for quality, and the confusing instructions from\nHCFA and OIG.\n\nSee The Sanction Referral Authority of Peer Review Organizations.\n\n16. Federation of State Medical Boards of the U. S., Inc., Annual Board Action Statistical\nPackage, April 5, 1995.\n\n\n\n\n F-2\n\n\x0cMany medical boards are beginning to devote more attention to quality-of-care cases. But\nmost disciplinary actions taken by boards still focus on other issues, such as drug and\nalcohol abuse, sexual abuse, and criminal violations.\n\n17. Concerns about violating confidentiality requirements explain, at least in part, why so\nlittle sharing has occurred. In 1990, Congress passed legislation calling for the PROS to\nshare information with the boards, but it has had little if any effect. It included a\nprovision that the sharing occur after the PROS\xe2\x80\x99 grant physicians \xe2\x80\x9cnotice and hearing. \xe2\x80\x9d\nBecause of uncertainty about the meaning of this \xe2\x80\x9cnotice and hearing\xe2\x80\x9d provision, however,\nPROS still shared little information with the boards. (see The Peer Review Organizations\nand State Medical Boards: A Vital Link)\n\n18. Citizen Advocacy Center, Information Exchange Between Peer Review Organizations\nand Medical Licensing Boards: Update and Repoti on CAC Survey, March 1992, and\nInformation Exchange Between Peer Review Organizations and Medical Licensing Boards:\nRepoti on the 50 State Survey, November 1992.\n\n19. The Center identified Alabama, California, Colorado, Iowa, Minnesota, Mississippi,\nOhio, Rhode Island, West Virginia, and Wisconsin as States with medical boards and\nPROS both committed to sharing information.\n\n20. For example, the New York PRO initiated a cooperative project aimed at improving\nprophylactic antibiotic administration. It collaborated with more than 70 hospitals to\nconduct this project and, based on the project\xe2\x80\x99s feedback, these hospitals are changing\ntheir antibiotic administration policies. (from \xe2\x80\x9cIPRO Works with Hospitals to Implement\nFeedback Effort, \xe2\x80\x9d IPRO Quality Initiatives, Winter 1995.)\n\nAnother example involves the Alabama PRO\xe2\x80\x99s use of data from the large-scale\nCooperative Cardiovascular Project. By working with the PRO, one hospital in Alabama\nincreased the proportion of patients receiving beta blockers when indicated from one-third\nto all. It also increased the post-heart attack administration of aspirin from 70 percent to\n95 percent of eligible patients. (from Linda Oberman Prager, \xe2\x80\x9cUndoing Case Review, \xe2\x80\x9d\nAmerican Medical News, June 26, 1995.)\n\n\n\n\n F-3\n\n\x0c'