Summary: In response to a congressional request, GAO reviewed: (1) the Health Care Financing Administration's (HCFA) medical review systems for measuring and monitoring Medicare quality of care; and (2) quality assessment research and evaluation within the Department of Health and Human Services (HHS).
GAO found that: (1) there was no legislative requirement for nationally representative information on levels of quality or problems related to quality of care in covered services or on the overall health care provided; (2) HCFA oversight of carriers', intermediaries', and peer review organizations' (PRO) medical review activities focused only on whether they met contract specifications, rather than their effectiveness in identifying quality problems; (3) although carriers, intermediaries, and PRO devised systems for identifying and addressing particular types of quality problems, they had not coordinated their efforts; (4) because there was no information available to document how the review efforts were working, it was not known whether PRO effectively identified and corrected quality-of-care problems; (5) HCFA had no comparative information on the effectiveness of the quality review methods used for health maintenance organizations (HMO) and competitive medical plans (CMP); (6) HCFA did not require claims processors to include diagnostic information in their Medicare Part B billing forms or to enter the information into the billing files; (7) since the SuperPRO contractor did not adequately record the reasons for its random selections of PRO case reviews, the PRO data were not comparable or nationally representative; and (8) HHS had no clear strategy or organizational structure for integrating information on the quality of health care provided to Medicare beneficiaries or for developing methods and knowledge to meet future needs.
