MEDICARE: Complaint Investigation Secrets Cause Concern

      The Seattle Times yesterday looked at the "secretive" process of investigating Medicare beneficiary complaints concerning the quality of medical care they receive. Deliberations are never disclosed during the process, and information on physicians is not provided without their permission. HCFA is legally committed to ensure the privacy of medical practitioners, and HCFA Director of Clinical Standards and Quality Dr. Jeffrey Kang argues that this confidentiality is necessary because "we reduce future errors by learning from our own mistakes. But no one is willing to admit a mistake if you know it's going to be public." But at a time when care quality and patients' rights are major national concerns and the government looks to consumer input for policy improvement, the appearance of a lack of accountability has angered many patients and advocates. King County, Wash., ombudsman Vicki Elting considers the confidentiality rule to be "a major flaw in the system," discouraging many seniors from filing complaints. When called on to investigate quality of care complaints, HCFA contracts with private companies, called peer-review organizations, to determine whether patient services meet health-care standards, are medically necessary and are delivered in the most appropriate setting. As Kang explained, the main purpose of the review "is not a full hearing of the beneficiaries' complaint, but [rather] for improving the care of everyone." According to California attorney Lenore Gerard, HCFA claims the peer-review system is offered as a proper redress for consumers' complaints, but "[i]f it's only intended as a broader check, then in fact there is no effective redress." A 1995 Office of the Inspector General report said that 10-15% of quality-of-care complaints were justified, but 77% of Medicare beneficiaries were unaware of the peer-review process. Despite report recommendations requiring the peer-review organization to inform consumers of its investigative methodology, HCFA has failed to do so (King, 8/22).