Assuring Quality of Care for the Elderly

Division of National Cost Estimates, Office of the Actuary, Health Care Financing Administration. “National Health Expenditures, 1986–2000”. Health Care Financing Review 8(4):1–36, 1987; Committee on Ways and Means, U.S. Congress, House of Representatives. Background Material on Programs Within the Jurisdiction of the Committee on Ways and Means. Washington: U.S. Government Printing Office, March, 1989.

For a recent examination of utilization management, see Institute of Medicine. Controlling Costs and Changing Patient Care? The Role of Utilization Management. Gray B.H. and Field M.J. , eds. Washington, DC: National Academy Press, 1989. The Institute of Medicine currently is conducting two studies on practice guidelines; the final report of one study being done for the Forum on Quality and Effectiveness in Health Care of the Agency for Health Care Policy and Research will be released in mid-1990 (Institute of Medicine. Clinical Practice Guidelines: Directions for a New Program. Field M.J. and Lohr K.N. , eds. Washington, DC: National Academy Press, 1990).

For instance, the United States ranks among the top ten countries in life expectancy for persons who have attained age 65—almost 15 additional years for men and almost 19 for women. See National Center for Health Statistics, Public Health Service, U.S. Department of Health and Human Services. Health United States 1989. Washington, DC: U.S. Government Printing Office, forthcoming.

Institute of Medicine. Medicare: A Strategy for Quality Assurance. Lohr K.N. , ed. Volumes I and II. Washington, DC: National Academy Press, 1990. See also: Lohr K.N. and Schroeder S.A. “Special Report. A Strategy for Quality Assurance in Medicare.” New England Journal of Medicine, 1990, 322:707–712. The proceedings of an invitational conference held in May 1990 to explore further the IOM committee's findings and recommendations will be published as New Directions for Medicare Quality Assurance: Proceedings of a Conference. Lohr K.N. Donaldson M.S. and Harris-Wehling J. , eds. Washington, DC: National Academy Press, forthcoming.

The methods and results of these two sets of focus groups are described in A.J. Walker, “Results of the Medicare Beneficiary and Physician Focus Groups”. Pp. 35–90 in Medicare: A Strategy for Quality Assurance. Volume II. Sources and Background Materials. Lohr K.N. , ed. Washington, DC: National Academy Press, 1990.

The methods and results of the public hearings and written testimony analysis are described in J. Harris-Wehling. “Oral and Written Testimony from the Public Hearings”.” Pp. 7–34 in Medicare: A Strategy for Quality Assurance. Volume II. Sources and Background Materials. Lohr K.N. , ed. Washington, DC: National Academy Press, 1990.

Three of those papers will be published by the Health Administration Press in a forthcoming monograph: R.H. Palmer on definitions of quality of care; A. Donabedian on barriers to quality assurance; and G. Povar on bioethical aspects of quality assurance.

The methods and results of the site visits analysis are described in Donaldson M.S. and Lohr K. N. . “Site Visits”.” Pp. 91–115 in Medicare: A Strategy for Quality Assurance. Volume II. Sources and Background Materials. Lohr K.N. , ed. Washington, DC: National Academy Press, 1990.

See, for instance: Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals, 1990. Chicago, Ill: Joint Commission, 1989; Office of Technology Assessment. The Quality of Medical Care. Information for Consumers. OTA-H-386. Washington, DC: Congress of the United States, Office of Technology Assessment, June 1988. The background to the IOM's definition is more fully discussed in Harris-Wehling J. “Defining Quality of Care”. Pp. 116–139 in Medicare: A Strategy for Quality Assurance. Volume II: Sources and Background Materials. Lohr K.N. , ed. Washington, DC: National Academy Press, 1990.

Donabedian A. , “Evaluating the Quality of Medical Care”, Milbank Memorial Fund Quarterly, 1966, 44:166–203 July (Part 2); Donabedian A. , Explorations in Quality Assessment and Monitoring. Volumes I – III. Ann Arbor, Mich.: Health Administration Press, 1982, 1984, 1985.

Berwick D.M. , “Sounding Board. Continuous Improvement as an Ideal in Health Care”, New England Journal of Medicine, 1989, 320: 53–56; Batalden P.B. and Buchanan E.D. , “Industrial Models of Quality Improvement, in Providing Quality Care: The Challenge to Physicians. Goldfield N. and Nash D.B. , eds. Philadelphia: American College of Physicians, 1989.

PSROs were established in 1972 to assure that physicians and institutions met their Medicare obligations; such obligations required that services provided or proposed to be provided to Medicare beneficiaries were medically necessary, of a quality that met local professionally recognized standards, and were provided in the most economical manner consistent with quality of care. PSROs were voluntary, not-for-profit, local physician organizations. The program was administered by the Health Care Financing Administration, which used a complicated system of annual grants to PSRO entities consisting partly of congressionally appropriated general revenues and partly of Medicare Trust Fund monies. PSROs carried out the following activities: Hospital utilization review, development of hospital discharge data, so-called profile analysis. Medical Care Evaluation (MCE) studies and Quality Review Studies, and review of care rendered in settings other than hospitals, such as nursing home and ambulatory care. The emphasis throughout the PSRO program was on controlling use and, more importantly, costs. The program could not demonstrate that it saved much if any more money than it cost, however, and did not conclusively document improvements in quality of care. By the early 1980s, therefore, disappointment and frustration with the program were widespread, and it was replaced with the PRO program. More thorough descriptions of the PSRO program can be found in Goran M.J. Roberts J.S. Kellogg M.A. . “The PSRO Hospital Review System”, 1975, Medical Care (Supplement), 13:1–33; Blum J.D. Gertman P.M. and Rabinow J. . PSROs and the Law. Germantown, Md.: Aspen Systems Corporation, 1977; it is also discussed in Volume 1, Chapter 6, of the IOM report cited earlier.

For an early discussion of the PRO program, see Dans P.E. Weiner J.P. and Otter S.E. , “Peer Review Organizations: Promises and Pitfalls.” New England Journal of Medicine, 1985, 313:1131–1137. K. N. Lohr, in Peer Review Organizations: Quality Assurance in Medicare. P-7125, Santa Monica, CA: The RAND Corporation, 1985, describes the lengthy implementation of the PRO program with special emphasis on its quality of care dimensions. The IOM report on this study (cited in Note No. 3) deals extensively with the PRO program, especially in Chapter 6 of Volume I and Chapter 8 of Volume II.

Those tasks include generic quality screening conducted by nurse reviewers, who can determine that a case passes the screens. If a case fails any screen and has a potential quality problem, then it must be referred to a physician advisor for further evaluation; only the physician advisor can “confirm” a quality problem. Discharge review is intended to flag problems with premature discharge when the patient was not medically stable at discharge or when discharge was not consistent with the patient's continued need for acute inpatient care. Retrospective admission review identifies whether inpatient hospital care was medically necessary and appropriate, by reviewing reasons for admission against pre-established criteria devised or adopted by individual PROs. Invasive procedure review retrospectively examines the medical necessity of invasive procedures that affect the assignment of a case to one DRG rather than another. Depending on whether the entire admission or just the procedure is considered unjustified, payment for all of the admission or the procedure may be denied. DRG validation assures that cases are accurately classified for Medicare payment under PPS, and coverage review determines whether items or services normally excluded from Medicare coverage are medically necessary and thus covered. Chapter 6, Volume I and Chapter 8, Volume II of the IOM report (see Note No. 4) describe these and other required PRO activities in greater detail.

The PSRO program was hampered by its relatively limited ability to act on this presumed regulatory power and to bring or recommend sanctions against providers. To gain the acceptance of the provider community in the early years, some congressional supporters and some executive branch directors of the program emphasized the quality-of-care (rather than the cost-control) thrust of the program (see, for instance, Blumstein J.F. , “Inflation and Quality: The Case of PSROs”, in Health—The Victim or Cause of Inflation? Zubkoff M. , ed. New York: Prodist (for the Milbank Memorial Fund), 1976). In quality assurance terms, this translated into an “educational” rather than a “regulatory” program. The ambiguity inherent in an “educational-regulatory” stance was never successfully resolved, and it remains a potential stumbling block for any similar effort.

The OIG must determine whether the PRO followed appropriate procedures, whether a violation occurred, whether the provider has “demonstrated an unwillingness or lack of ability substantially to comply with statutory obligations” (known as the “willing and able” provision”), and ultimately whether it agrees with the PRO recommendation (for more details, see OIG, The Utilization and Quality Control Peer Review Organization (PRO) Program. An Exploration of Program Effectiveness. Washington: Office of Inspector General, Office of Analysis and Inspections, October, 1988). The OIG can sustain the PRO recommendation, alter it, or reject it. If the OIG proceeds successfully with these steps, the Secretary, through the OIG, can apply two kinds of formal sanctions: (1) exclusion from the Medicare program (for one or more years) and (2) monetary sanctions (which at present cannot exceed the cost of the services rendered). Excluded hospitals and providers must petition to be reinstated in the Medicare program, and they can receive (with a few exceptions) no payment for services rendered or items provided during the exclusion period.

See Jost T. , Administrative Law Issues Involving the Medicare Utilization and Quality Control Peer Review Organization (PRO Program: Analysis and Recommendations. Report to the Administrative Conference of the United States. Washington, DC: Administrative Conference, November 8, 1988, reprinted in Ohio State Law Journal 1989; 50(1).

Among the important developments occurring while the IOM study was in progress was the creation of the Agency for Health Care Policy and Research (AHCPR) in the U.S. Public Health Service (by the Omnibus Budget Reconciliation Act of 1989). In addition to traditional concerns of health services research addressed by its predecessor agency, the National Center for Health Services Research, AHCPR has considerably expanded responsibilities for supporting the development, dissemination, and evaluation of practice guidelines and for conducting research in the area of effectiveness of medical care and outcomes of care.