HCFA’s peer review agencies turn collegial, but keep clout
A kinder, gentler PRO? Or a wolf in sheep’s clothing?
As hospital caregivers welcome the kinder, gentler role of peer review organizations (PROs) in the evolving peer review format, some Medicare observers are sending out advisory warnings. Yes, the Health Care Financing Administration (HCFA) may be using the carrot, but it has not let go of the stick, says Alice G. Gosfield, JD, principal of Alice G. Gosfield & Associates, a Philadelphia law firm dealing with health care law and regulations.
"The subtext of HCFA’s message may be Hi, we’re from the federal government. We’re here to help. We’re all going to do studies together. Isn’t this a wonderful thing?’" says Gosfield, who has worked with PROs for nearly 25 years. "By the same token, no one should be misled as to what the statutory authority of these organizations is."
Since the introduction of the Health Care Quality Improvement Program in 1993, the Baltimore-based HCFA’s goal has been to spur quality improvement efforts, develop critical pathways, and encourage measurement of outcomes data. (See related article on PROs’ role in Tennessee, p. 131.) These objectives are achieved by analyzing patient charts to see how health care organizations meet well-accepted quality indicators. PROs can advise institutions on how to improve in certain areas. They even offer health care organizations bona fide pathways and guidelines that have worked at other hospitals.
But while much attention has focused on the evolving collaborative tone HCFA has taken, Gosfield looks to the small print of PRO mission statements. "In the back, there are these one-sentence provisions that talk about reporting providers," she says. "It is quite clear that all the current energy and impetus are geared toward quality improvement, but that doesn’t mean that they don’t have the ability to do the stuff that they have always done."
In addition, Gosfield highlights The Health Insurance Portability and Accountability Act, signed in August by President Bill Clinton. The statute contains provisions that spell out new sanctions against practitioners who fail to comply with statutory obligations, including Medicare rules. The dollar penalty that can be imposed has changed from the actual or estimated cost of services that were overutilized to up to $10,000 per incident.
Gosfield adds that, as always, PROs have the authority to recommend that physicians be thrown out of Medicare in addition to assess financial penalties. "[Hospitals’ administration] should understand that despite this shift in emphasis, that the authority of the program remains as it always has been. They need to sit up and pay attention."
QI approach provides results
Cardiac caregivers across the country have tested the waters first in the Health Care Quality Improvement Program with the pilot program, Cooperative Cardiovascular Project. In Tennessee, for example, HCFA abstracted eight months of records for acute myocardial infarction cases (DRG 410) at 120 participating Tennessee hospitals. The Memphis, TN-based Mid-South Foundation for Medical Care, the Tennessee PRO, reviewed the data and presented confidential profiles showing how well the facility performed on five key processes. (See results, p. 132.) In addition, Mid-South also provided each hospital with anonymous comparisons with similarly sized institutions on a state and national level.
"We want to find out what they are doing right, not what they are doing wrong," says Stephen Winbery, PhD, MD, principal clinical coordinator at Mid-South. "HCFA is now a cooperative agency. They have moved from looking for bad docs and high lengths of stay and into the mainstream of QI [quality improvement]. We want to find out how these facilities can get better."
Winbery points to one hospital that almost immediately showed the benefits of a QI-focused peer review. One measure in the Cooperative Cardiovascular Project for acute MI patients was that patients diagnosed with a heart attack who could receive aspirin did receive aspirin. This happened only 36% of the time prior to Mid-South’s analysis of the hospital’s charts. Six months later, 83% of acute MI patients were receiving aspirin.
The emergency department staff developed a protocol describing which patients should receive aspirin and when it is indicated. Winbery provided advice and sample aspirin-use flowcharts to the hospital. "It was just a matter of having [the protocol] there. By making people aware of certain situations, you can make a big difference," he says.
"That’s the notion of how it is supposed to work," Gosfield says. "On the other hand, [the PROs have all these other things they can do. Is there anything to be feared out of what the PRO does? The answer is Yes.’"
Facing the critics
In his testimony to Congress, Bruce C. Vladeck, PhD, HCFA administrator, acknowledged problems with the old peer review model. "We have come to believe that a look-behind, case-by-case examination of individual clinical events for errors is less effective in improving the quality of care than a more global and prospective approach that identifies patterns of care and health outcomes across a larger sample of patients."
But an April 1996 report by the U.S. General Accounting Office (GAO) in Washington, DC, cautioned that the old model had some merit. It argues:
• By virtually eliminating random-sample case-by-case reviews, HCFA would lose the opportunity to identify providers delivering poor care.
• The number of targeted reviews planned could be minimal.
• Provider participation in PRO projects is purely voluntary.
"The ability of HCFA’s proposed program to focus on dealing effectively with poorly performing providers is not clear, and this is an area where HCFA has not performed well in the past," the GAO states.
"Lighten up," says Connie Harrison, RN, MSN, quality consultant in the Quality Resources Department of Vanderbilt University Medical Center in Nashville. She does not see HCFA’s QI focus as a question of being too lax or too strict. She views it as the difference between being unproductive and productive. Vanderbilt was one of the first health care centers to participate in the new peer review format.
"[The PROs] are using a more effective technique to process improvement that looks at trends in the data instead of having knee-jerk reactions to one event, which is what they did in the past," Harrison says. "They will still be able to keep the pulse of the variations in patient care processes. . . . There is no benefit to being so strict."
As the GAO points out, participation in the program is voluntary, unless a serious quality of care problem occurs, such as removing a healthy body part accidentally. Then mandatory participation would be required. But, as Winbery says, there is little downside to participating. HCFA even pays for photocopying the charts at 8 cents per page. Not only do participating hospitals get essentially free QI advice, participating in the project satisfies many quality improvement standards of the Joint Commission on Accreditation of Healthcare Organizations.
If an organization has significant quality of care problems and refuses to work with the PRO to resolve those problem, HCFA can and will assess stiff fines and penalties up to halting Medicare payments, says Winbery. Such organizations represent a small minority of hospitals, he says. In fact, no Tennessee hospital has been so bad as to warrant mandatory participation, and no hospital has refused to work with Mid-South.
[Editor’s note: For more information, contact your individual state peer review organization or Stephen Winbery, PhD, MD, Mid-South Foundation for Medical Care, 6401 Poplar Ave., Suite 400, Memphis, TN 38119; (901) 682-0381.]
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