:( 

Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

MONITORING SERVICES PROVIDED

IN PHYSICIANS' OFFICES

'fRVICESO 
Richard P. Kusserow 
INSPECTOR GENERAL 
'0  OEI-02-90-0041O 
;fIiVd3G  EXECUTIVE  SUMMARY

PURPOSE 
To identify and describe the CUITent private sector and Medicare initiatives to improve the 
monitoring of services provided by physicians in their offices. 
BACKGROUND 
In the past few decades, much of the emphasis given to controlling the utilization and cost of 
health care has been in the public sector, primarly with the Medicare and Medicaid programs. 
These programs have made extensive use of pre-payment and post-payment utilization review 
(UR) and medical review (MR) techniques in the processing of hospital and medical claims by 
contractors or State agencies.

The soarng cost of U.S. health care in the last 10 years (up from $230 bilion to $606 bilion in 
1989) has spuITed similar efforts in the private sector where large employers are seeking to 
control their rapidly escalating expenditures for health care. The private sector has looked to 
managed care (MC) programs to help solve this problem. These programs attempt to control 
rough the use of prior review 
costs by assessing the appropriateness of proposed care 

techniques, and by channeling patients to specific providers. Examples of major health deli very 
plans utilizing MC are health maintenance organizations (HMO) and prefeITed provider 
organizations (PPO). Together, these plans cover about 75 milion subscribers and family 
members nationwide. 
In the public sector, the Medicare program made Part B medical payments of $37 billion to 
about 33 milion beneficiares in 1989. Physicians are monitored by Medicare cariers through 
sophisticated computer programs. The Health Care Financing Administration (HCFA) has 
continued to build upon 25 years of experience with Part B MR by sponsoring Medicare carer 
studies to improve this process. In addition, HCFA is sponsoring PPO demonstrations involving 
an alternative service delivery model for beneficiares. 
In this report, MCIUR refers to all firms which provide DR and/or MR services, either 
independent of, or as part of, a MC program. 
METHODOLOGY 
In-person interviews were conducted with a purposive sample of 12 MCIUR firms (including 5 
of the nation s 10 largest general service DR firms) and 5 employers. The respondents selected 
provided or used MC plans with the most extensive monitoring of physician services provided in 
ambulatory settings. In addition, visits were made to two Medicare cariers and two PPOs 
involved in HCFA initiatives to develop utilization and alternative service delivery models.  FINDINGS 
Private Sector Monitoring Of Physicians' Services Provided In Their Offices Is Limited But 
Emerging 
Few MCIUR programs focus on services provided in physicians ' offices. 
A few MCIUR firms are using sophisticated computerized software systems in an 
effort to contain costs of physicians ' services and to develop appropriate patterns of 
ambulatory care based on diagnoses. 
Trade groups are also developing strategies to address ambulatory care. 
Most MCIUR firms employ some specific quality assurance techniques. 
HCFA' s Initatives Explore New Ways To Monitor Services Provided In Physicians' Offices 
The Blue Cross Blue Shield of Arizona and Capp Care PPO demonstrations wil 
allow HCFA to evaluate a private sector MC model's potential for providing quality 
care to Medicare beneficiaries while containing costs. 
The Blue Cross Blue Shield of North Dakota (BCBS/N) study has developed data 
on diagnosis-based patterns of care MRR screens. 
Blue Cross Blue Shield of Indiana and Blue Cross Blue Shield of Arkansas are 
Flexibility Control Carers" HCFA is evaluating as part of a controlled study. 
These carrers have been given greater MRIR flexibility to find innovative ways to 
improve Medicare operations. 
CONCLUSION 
The HCFA appears to be on the cutting edge of efforts to improve the monitoring of services 
provided to Medicare beneficares by physicians in their offces, and to explore alternative 
service delivery systems for beneficiares.  ... ............... .... ............... ...... ........ ............ ... .. .................. ...... ....... .................. ....... . ......... ..... .... ............... ......... ......... ... ................,................ ........... ........ ........ ......... ......... ........ ........ .............. ...... ............ ........ ... .... ........ ........ ........ ........ ....... ...
TABLE OF CONTENTS

EXECUTIVE SUMMARY 
INTRODUCTION.......... 

Purpose.. .. .... 
Background ................ .................. ........ 

Methodology........................ ................................................................................

FINDINGS................................................................................................................ 

CONCLUSIONS  1 a  INTRODUCTION

PURPOSE 
sector and Medicare initiatives to improve the 
To identify and describe the CUITent private 
monitoring of services provided by physicians in their offces. 
BACKGROUND 
In the past few decades, much of the emphasis given to controllng the utilization and cost of 
health care has been in the public sector, primarly with the Medicare and Medicaid programs. 
These programs have made extensive use of pre-payment and post-payment review techniques in 
the processing of hospital and medical claims by contractors or State agencies. They have also 
engaged Professional Review Organizations (formerly Professional Standards Review 
Organizations) to review the medical necessity of hospital admissions and stays. Also, the 
Public Health Service (PHS) has a 1989 legislative mandate to develop clinical guidelines over 
the next several years to enhance the quality, appropriateness and effectiveness of health care. In 
developing standards of quality, PHS wil be stressing oUtcomes, to help health care practitioners 
and others who review health care to assure its quality. 
The soarng cost of U.S. health care in the last 10 years (up from $230 bilion to $606 bilion in 
1989) has spuITed similar efforts in the private sector where large employers are seeking to 
control their rapidly escalating expenditures for health care. The private sector has looked to 
managed care (MC) programs to help solve this problem. About 300 MC firms nationwide 
cUITently provide or arange for review of services on a packaged or customized basis to 
employers, unions and insurers; some employers and insurers provide this service themselves. 
The MC approach attempts to control costs by assessing the appropriateness of proposed care 
through the use of prior review techniques and by channeling patients to specific providers. 
EXilmples of major health delivery models utilizing MC are health maintenance organizations 
(HMO) and prefeITed provider organizations (PPO). While HMOs evolved out of public sector 
initiatives in the 1970s, PPOs are a private sector development of the early 1980s. They 
generally do not offer the full range of services found in HMOs, but provide more benefits than 
enrollees receive in conventional plans. 
At present, about 600 HMOs operate nationwide, with reported enrollments of around 35 
milion. Among these HMOs are approximately 105 plat.s with Medicare contracts enrolling 
almost 2 million beneficiares. The number of operational PPOs in the U. S. has increased 
dramatically, from 25 in 1981 to around 800 in 1990; they serve an estimated 42 milion workers 
and family members. No CUITent data is available on the actual size of physician membership in 
either HMOs or PPOs, although about half of all physicians in the U.S. are estimated to be 
members of one or more MC health plans.  In the public sector, the Health Care Financing Administration (HCFA) is the primary insurer of 
about 33 milion Medicare beneficiares. In 1989, the Medicare program made Par B medical 
payments of $37 bilion. For calendar year 1988, the program experienced nearly 124 milion 
visits to physicians ' offces, and paid about $3. 2 bilion for Part B medical services in that 
setting. 
Physicians are monitored by Medicare carers through sophisticated computer programs. Often 
program dollars are withheld or are recovered from providers when the medical necessity of 
services is not established. The HCFA has continued to build upon 25 years of experience with 
Par B service review by sponsoring Medicare carer studies to improve this process. In 
addition, HCFA is sponsoring PPO demonstrations involving Medicare beneficiaries. 
Other Federal agencies also utilize MC health plans. About 1.8 milion Federal employees 
retirees and dependents are enrolled in HMOs through the Federal Employees Health Benefits 
Program - up 16 percent from 20 years ago. The Civilian Health and Medical Program of the 
Uniformed Services makes MC available to 900,000 beneficiaries through PPO networks in 
California and Hawaii. 
The term "ambulatory" care, as used in this report, includes, but is not limited to, services 
physicians provide in their offices. Monitoring refers to the application of techniques used to 
review the actual or proposed utilization of all care for its appropriateness and necessity. 
Utilization review (DR) is a term generally applied to inpatient hospital care, while medical 
review (MR) is a term generally applied to ambulatory care. In this report, MCIUR refers to all 
firs which provide UR and/or MR services, either independent of, or as part of, a MC program. 
METHODOLOGY 
Mail contact was made with all of the 86 MCIUR firms attending a March 1990 "UR Summit 
conference of the American Managed Care and Review Association (AMCRA). Information 
was requested regarding the specific services offered by each to its clients. In addition , the 
Washington Business Group on Health (WBGH) furnished, at our request, a list of 15 large 
employers utilizing MC health plans for their employees. These employers were contacted by 
phone and mail and asked to provide information about their health care plans. Forty-seven 
MCIUR firs furnished the requested information. Other firms did not respond, or indicated 
they were not performing MCIUR for ambulatory care. All the employers were contacted but 
only 10 offered MCIUR plans to substantial numbers of employees. 
From those respondents, a purposive sample of 12 MCIUR firs (including 5 of the nation s 10 
largest general service UR firms) and 5 employers was selected for onsite visits. The 
respondents selected provided or used MC plans with the most extensive monitoring of 
physician services provided in ambulatory settings. In addition, visits were made to two 
Medicare carers and two PPOs involved in HCFA initiatives to develop utilization and 
alternative service delivery models. Detailed information was collected about each 
organization s MRIR activities, quality assurance practices and provider relations. Employers 
were asked about how health care plans offered to employees were selected and their experience  with MC firs. This information was complemented by statistical and survey data from the 
Midwest Business Group on Health (MBGH), the American Medical Association (AMA), the 
Blue Cross Blue Shield Association (BCBSA), the American Managed Care and Review 
Association (AMCRA), the Group Health Association of America (GHAA), the American 
Association for Retired Persons (AARP), the Health Insurance Association of America (HIAA) 
and HCFA.  FINDINGS

PRIVATE SECTOR MONITORING OF PHYSICIANS' SERVICES PROVIDED IN 
THEIR OFFICES IS LIMITED BUT EMERGING 
Few MC/UR programs focus on services provided in physicians' offices. 
The focus of MCIUR has been on inpatient hospital services with special concern for mental 
health and substance abuse cases (MHSA). All 47 responding MCIUR firms provide 
comprehensive programs for managing inpatient hospital services and some ambulatory services. 
Most of these firms (37 of 47) perform UR of inpatient hospital and ambulatory MHSA services. 
Four specialize in MCIUR for MHSA services. 
While twenty-two of the 47 firs report performing some varety of ambulatory care review, the 
extent is quite limited. Seventeen of these 22 firms limit ambulatory care review to prospective 
certification of selected procedures or procedures over a certain dollar amount. Some also 
perform retrospective review of targeted ambulatory services, such as chiropractic care. Only 
the remaining five firms are using relatively new and highly sophisticated computer software 
systems to monitor services provided in a physician s office. 
The lack of private sector experience with the monitoring of physicians ' in-office services was 
Medical Utilization Review 
noted in a recent issue of  an industry newsletter: 
CUITently, carers and other vendors of UR management services are promoting new 
ambulatory care UR systems. However, employers must keep in mind that ambulatory 
care UR is immature and has not yet evolved to the same degree as inpatient UR. 
(Faulkner & Gray  Healthcare Information Center  Washington, D.  , October 25, 1990) 
Afew MC/URfirms are using sophisticated computerized software systems to contain costs of 
physicians  services and to develop appropriate patterns of ambulatOlY care based on 
diagnoses. 
The computer programs used by four of the five MCIUR firms which review in-office services 
screen physicians prospectively (where prior utilization data is available) and identify physician 
member outliers through sophisticated data base management programs. The firms get outliers 
to conform to acceptable utilization levels or drop them from their HMO and PPO networks. In 
contrast, Medicare law permits HCFA to exclude a physician from paricipation because of 
excessive utilization only as the result of a long and complex sanctions procedure, usually 
related to a quality of care issue.

Three of these MCIUR firs, including two insurers, utilize an adaptation of a patented software 
program that measures services biled against established standards of treatment based on 
diagnoses. A key element in the patented program is the use of local physician control and input. 
However, the three firms have obtained little or no local medical community input in adapting  the program. All use the system primary on a prospective basis, to determne appropriateness 
of services based on the established guidelines. 
According to these respondents only about 40 organizations nationwide, including major 
insurers and HMO networks, use the patented software program for this purpose. The total 
population covered by all these programs is estimated to be three million, or less than five 
percent of all those estimated to be covered by MC plans. 
Indications are that the popularty of such programs is growing. Similar types of software have 
been developed or are being developed. The insurers and MCIUR firms using them say they 
now have a clearer picture of where health care costs are located. More time is needed, however 
to adequately assess financial impact and employer and subscriber satisfaction. 
Trade groups are also developing strategies to address ambulatory care. 
The HIAA has proposed a strategy to achieve effcient and high-quality health care in the private 
sector through a public-private insurance system. Such a system would include efforts to 
channel patients to efficient, high-quality providers, and to promote and paricipate in the 
development, dissemination and use of outcome-based medical guidelines and protocols as a 
means of improving the quality of patient care. 
According to the MBGH, major strategies cUITently being pursued by employers include 
developing employer-sponsored purchasing initiatives for specific procedures or comprehensive 
service, and requiring quality and cost-containment features from insurers and providers as a 
basis for contracting. 
Recently, the AMA, HIAA, BCBSA and AMCRA formed a task force to develop national 
utilization review guidelines for inpatient hospital services. Down the road, a similar effort is 
planned for out-of-
hospital services. 
Most MC/URfinlls employ some specifc qualiy assurance techniques. 
Seven of the sample MCIUR firms select physicians for health care plans, based on rigorous 
credentialing which screens physicians prospectively, and analysis of utilization data to identify 
These are quality assurance (QA) techniques used by all. Credentialing 
abeITant practices. 
committees are used by these firms to develop, maintain and apply the qualifications standards 
necessar in the selection of physicians wishing to join the HMO or PPO plans. Data is 
collected on medical specialty and licensure, board eligibility or certification, medical education 
professional liability coverage, hospital affiliation(s), preference as to participation as either a 
primary care physician or specialist, call coverage and other administrative information. Some 
of these firms also conduct consumer satisfaction surveys. (In contrast, a physician providing 
services to Medicare beneficiares need only be licensed in the State of practice in order to be 
reimbursed. 
One large insurer among these seven firms has an extensive credentialing process for physicians. 
All physicians in an area selected for the development of a network are invited to focus group  discussions. Their perceptions and attitudes towards MC, PPOs, utilization review and other 
topics are collected. Preliminary screening consists of checks for prior sanctions or disciplinary 
action, board eligibility or certification, malpractice history, and hospital staff privileges. 
addition, provider relations staff visit every provider s office to check for modern and sanitary 
conditions, adequacy of waiting room area, administrative as well as record keeping procedures 
and additional aspects of the physician s practice. This usually takes up to 3 months to complete. 
Following selection, provider relations staff visit every primar care physician in the network at 
least quarterly to discuss any problems, complaints or areas of concern of either party. 
For the most part employers do not get involved in the particulars of quality assurance but 
instead rely on MC firms to perform these duties. The five major employers visited either use 
internal medical staff or QA coordinators to monitor quality, but most of the emphasis is on 
inpatient care. These employers all use survey instruments to determine employee satisfaction 
with their CUITent health plans and as a way to spot poor quality care. 
Comprehensive quality review procedures involving proactive approaches are generally not 
found in MCIUR firms affiliated with PPOs. As PPOs are a recent innovation in the health care 
market, little evidence is available about their effects on health care costs, quality of care or 
patient satisfaction. 
The firs visited rely mainly on contact with the providers through prior authorization of 
specific services, e.  , elective surgery, to assure quality and appropriate care. However, HMO 
plans are generally required to have a formal QA program in place, as was the case with four of 
the sample MCIUR firms affiliated with HMOs. 
About 75 percent of nearly 600 active HMO plans nationally meet Federal standards and most 
States also regulate them. These HMOs have QA programs which include some review of 
in-office services. PPOs are exempt from the State and Federal regulations governing HMOs. 
Some of the MCIUR firms visited said that a barer to assuring quality of care was the lack of an 
acceptable definition of quality. In this regard, the Institute of Medicine s (10M) 
Committee to Design a Strategy for Quality Review and Assurance in Medicare, formed at the 
behest of the Congress as a result of OBRA 1986, defined quality of care in its 1990 report as 
the degree to which health services for individuals and populations increase the likelihood of 
desired outcomes and are consistent with CUITent professional knowledge. " The 10M study 
noted with regard to ambulatory care: 
Both overuse and underuse of services are of concern in the physician-office setting ... We 
know far less about methods for reviewing the quality of care in the ambulatory setting 
than those for inpatient care. In the coming years, information from PRO pilot projects, 
HMO experiences, and research and demonstration studies focusing on outcomes 
management in ambulatory care should help to close that gap....  HCFA' S INITIATIVES EXPLORE NEW WAYS TO MONITOR SERVICES PROVIDED 
IN PHYSICIANS' OFFICES 
The HCFA's efforts to monitor physician services more effectively and study alternative service 
delivery models have resulted in varous initiatives. Two of five PPO demonstrations planned by 
HCFA are under way and a third is being considered. The Blue Cross Blue Shield of Arizona 
(BCBS/AZ) private business PPO and Capp Care PPO of California are demonstration sites. 
Each is required by HCFA to maintain a strctured QA program. The HCFA also entered into an 
agreement with Blue Cross Blue Shield of North Dakota (BCBS/ND) for the development of 
diagnosis-based patterns of care MRIUR screens. Blue Cross Blue Shield of Indiana (BCBSIIN) 
and Blue Cross Blue Shield of Arkansas (BCBS/AR) have also been funded by HCFA as 
Flexibility Control Carers  ; each has been given greater MRR flexibility to find innovative 
ways to improve Medicare operations. Following are brief descriptions of each of these 
ini tiati ves: 
Blue Shield of Arizona Demonstration 
The Blue  Cross 
The HCFA contracted with Blue Cross Blue Shield of Arizona (BCBS/AZ) in 1988 for a 
Medicare demonstration of the PPO concept which marketed a Medigap policy (Senior 
PrefeITed) with lower premiums than usual and added benefits. A panel of 1 100 physicians was 
established from those who met and maintained PPO paricipation criteria set by BCBS/AZ for 
its own PPO. Physician profiling is the key means of exercising utilization control over 
physicians' services. The plan has not emphasized MRIR activity but monitors the physicians 
receiving the largest reimbursement. It relies less on the physician s ability to change behavior 
and more on having chosen efficient physicians in the first place through effective credentialing. 
The entire membership is reviewed according to formalized criteria on a bi-annual basis, 
including review of economic profiles and quality concerns. The contract signed by 
participating physicians can be terminated at any time by either pary. 
The BCBS/AZ has a strctured QA program which includes the Medical Offce Review and 
Evaluation Program (M.  R.E). This program, with its onsite visits and evaluations of 
physicians ' office and medical practices , includes reviews of the content of medical records, 
evaluation of offce facilities, safety and hygiene, laboratory and X-ray facilities and procedures. 
The M.  E. gives BCBS/AZ useful information for individual and peer quality assessments. 
The visits are conducted confidentially and the findings are shared with the member physician 
along with recommendations to COITect problems noted. Physicians are expected to implement 
the recommendations. 
Patient grevances serve as quality checks; BCBS/AZ is planning a patient satisfaction survey of 
Senior PrefeITed enrollees to assess their reactions to the provider panel and to the service and 
benefits.  Demonstration 
The Capp Care  PPO 
The CAPP CARE PPO demonstration started in Orange County, California and is due to expand 
to nine counties in Southern California. The pilot demonstration, open to all 188,000 Medicare 
beneficiares in Orange County, began operating in March 1990. Approximately 900 physicians 
participate. Providers must be wiling to accept assignment and comply with all biling 
guidelines and UR procedures. 
These physicians are par of CAPP CARE's private PPO.network and are subjected to a rigorous 
credentialing process, including licensure, liability claims, professional society complaints and 
other disciplinary indicators. In addition, a profie of each physician is gathered containing such 
information as medical school, specialty, board certification and hospital affliations. If a 
sufficient number of claims are available, physician-specific profiles are developed and 
compared to established normative values. Physicians whose practice profile shows a significant 
variation from established parameters are excluded. Physicians whose various profiles conform 
to CAPP CARE standards are eligible to join the network. 
The CAPP CARE demonstration has a quality assurance program for ambulatory services 
similar to the one it uses with its private payers. Ambulatory care review is performed using a 
computerized system that compares physician claims to normative values that are 
specialty-specific. The review is completely automated and data is run through edits that detect 
frequency of use of certain higher reimbursable codes and frequency of injections and laboratory 
tests. The system generates QA reports that detect abeITant biling practices and are reviewed by 
a QA committee. Ambulatory services are also monitored through a formal patient grievance 
system specifically designed for the Medicare PPO. It allows beneficiaries to register complaints 
and sets down guidelines for their effective resolution. 
The demonstration is a non-enrollment model which is fr.ee of risk to Medicare beneficiaries; 
participation is automatic any time they choose to see a plan physician. Marketing 
of the 
demonstration was limited to a mailing to all Orange County beneficiaries announcing the 
demonstration and providing a directory with the names, addresses and specialties of all 
participating physicians. 
The Blue Cross Blue Shield of North Dakota Patterns of Care Study, 
In March 1988, HCFA entered into an agreement with Blue Cross Blue Shield of North Dakota 
(BCBS/N) for the development of diagnosis-based patterns of care MRIR screens. These 
patterns included the full range of services generally provided to patients with a given diagnosis. 
The carer stared with 8 diagnoses based on volume of claims processed and reimbursed, e. 
cataract surgery. The carer added additional patterns, establishing 63 altogether. Each of the 
patterns was developed with the assistance and review of physician consultants and with general 
provider input. Acceptance by the medical community in North and South DakOta was 
necessar before implementation of the program began. 
Based on an agreement between the AMA and HCFA (Transmittal No. 1290, dated 2/89), the 
carer notified the providers in North and South Dakota that the MRIR system had been  developed. Meetings were held with peer review organizations and medical associations in both 
States to discuss the project, solicit comments and open a channel of communication with the 
medical community. 
The carer developed and implemented a computerized system for applying the new screens and 
began testing the program. Using the beneficiar histories and paid claims information in the 
system, it found that the screens were successful in identifying claims in need of further review. 
At present, all the carer data concerning this process has been turned over to HCFA for review 
and disposition. 
The Flexibilty Control Carrier Studies 
Blue Cross Blue Shield of Indiana (BCBSIIN) and Blue Cross Blue Shield of Arkansas 
(BCBS/AR) are "Flexibility Control Carers" HCFA is evaluating as part of a controlled study. 
These carers have been given greater MRIR flexibility to find innovative ways to improve 
Medicare operations. For BCBSIIN and BCBS/AR, HCFA has suspended or waived many 
MRIUR requirements other carers must meet, such as relevant CPEP standards, mandated 
screens, the 5 to 1 cost benefit ratio and prescribed postpayment review processes. The HCFA 
wil decide whether greater flexibility can produce a better MRIUR package. The study also 
involves Health Care Compare (HCC), a private sector MC fir performing MRIUR of Part B 
claims for Aetna Life of Georgia, the Medicare carer, under a subcontract. In this case, HCC 
must perform under the standard requirements governing all carers. 
The BCBSIIN, which was included in the study sample, has developed some innovative policies 
and practices to improve MRIUR. The development of medical policy is one such area. The 
carer has offered the State and local medical community an extensive role in the development 
of medical policies and MRIR guidelines. Every effort is being made to thoroughly research 
current literature on prospective policies, meet or otherwise communicate with medical specialty 
societies, the AMA and the CUITent Physician Terminology board for definition clarfication. 
The carer s Medical Director decides on the need for a policy, drafts and circulates it to an 
internal committee to assure conformity with regulations and law and to assess the practical 
aspects of implementation. Copies go to a Physician s Committee callng for a response within 
30 days. All comments are carefully considered and conflcts are resolved by the Medical 
Director by phone. The policy, published in a Medicare B Bulletin, takes effect 30 days later. 
Thus far, 110 new medical policies have been developed under the flexibility study. It appears 
that bringing the State and local medical community into. the policy-making process helps 
maintain better provider relations and makes enforcing policy guidelines more effective. 
The BCBSIIN has hired a programmer/researcher who uses the Statistical Analysis System 
(SAS) program to generate management reports and analyze MRIR data and trends. Part A 
utilization data are merged with Part B data in this program, so that review and analysis of all 
related services is possible. Validation audits are conducted of large Part B expenditures by 
specialty and provider. Refined reports are available to focus on utilization patterns of any 
provider and compare them with their peers.  carers 
The BCBSIIN is building a prototype SAS program that allows claims data from other 
and fiscal intermediares to be run through the SAS system and generate the same kind and 
number of management analysis reports. This would assure a consistent format among cariers 
for producing and analyzing utilzation data. 
CONCLUSIONS 
The HCFA appears to be on the cutting edge of activity to improve the monitoring of services 
provided to Medicare beneficares by physicians in their offces, and to explore alternative 
service delivery systems for beneficiares.