Medicare Review System Not Working, OIG Report Finds
The peer review system used to investigate quality of care complaints by Medicare beneficiaries is "ineffective and rarely punishes doctors and hospitals when they provide poor care," according to a report released today by the HHS Inspector General's office, USA Today reports (Appleby, USA Today, 8/13). Since 1987, Medicare Peer Review Organizations, or PROs, have been responsible for investigating beneficiary complaints. A 1995 OIG report found that the review process was "flaw[ed]," and the current report finds that it has "improved little over the past five years." Using a mail survey, "aggregate data on PRO complaints," visits to three PROs and a review of 82 complaints at those PROs, as well as other data, OIG investigators reached the following conclusions:
- PROs identified "quality problems" in 13% of beneficiary complaints between August 1997 and July 1999.
- However, in only six of 66 complaints with "confirmed concerns" did PROs call for "corrective action." These actions "rarely" included "any intervention beyond a letter."
- The accessibility of the peer review system is "questionable." In phone calls to 10 PROs, investigators "repeatedly reached busy signals" at two and recordings at another two. PROs themselves said that beneficiaries "often lack a clear understanding of the complaint process."
- Contracts between the Centers for Medicare and Medicaid Services (formerly HCFA) and PROs "treat complaints as a distinctly minor activity" and instead "stress quality improvement and payment reduction error."
- PROs "tend to be more oriented toward the medical community than to the beneficiary community" ("The Medicare Complaint Process: A Rusty Safety Valve," August 2001).
- Finally, highlighting the difficulty beneficiaries face in obtaining information about their complaints, in just 21% of cases where a quality problem was confirmed did the providers in question agree to release the details of the investigations, which is their choice under federal law.
"This system simply isn't working the way it's supposed to work," Principal Deputy Inspector General Michael Mangano said (USA Today, 8/13).
According to the report, CMS "responded positively" to the 1995 report, but has been "unable to publish a final rule ... revising the confidentiality regulations" of the peer review system. The new report makes two recommendations: CMS should "fix the complaint process within the existing PRO program" by making it a "prominent part of the PRO program, specify[ing] its expectations of an effective process through its contracts, consider[ing] different contracting approaches and hold[ing] the PROs more accountable for providing an effective complaint process." The report adds that CMS should create a new complaint process "outside of the PRO program" that could include "new mechanisms" such as mediation. CMS also could build on existing entities that already conduct similar work," such as state survey and certification agencies and state medical licensure boards, the report recommends. This option "would require legislative change" and "represen[t] a significant departure from how CMS has handled beneficiary complaints to date" ("The Medicare Beneficiary Complaint Process: A Rusty Safety Valve," August 2001). The full OIG report, OEI-01-00-00060, can be found in both HTML and PDF formats at http://oig.hhs.gov/oei/whatsnew.html.