., 

\

Department of Health and Human Servces


OFFICE OF


INSPECTOR GENERAL


EDUCATING PHYSICIANS RESPONSIBLE


FOR POOR MEDICAL CARE: A REVIEW


OF THE PEER REVIEW ORGANIZATIONS'


EFFORTS


.. SERVI(' .. . U: 

Richard P. Kusserow 

INSPECfOR GENERA 

cf:fa OEI-Ol-8-00 
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TABL. OF CONTENTS


EXECUTIVE SUMY 

INODUCTION. . 

FININGS ...................................................... 3


RECOMMNDATIONS 

COMMNTS ON TH DRA REPORT 

APPENDIX A 

Methodological Notes 

APPENDIX B 

Sample Overvew. . . . . . . . .. BAPPENDIX C 

Summary of Physician Profie Data. . . . . . . . . . . . . . . . . . i . . . . . . . . . . . .. CAPPENDIX D 

Generic Quality Screens. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' ' . . . . . DAPPENDIX E 

Summary of Intervention Profie Data . . . . . . . . . . . . . . . . . . . . . . . . . . . .. EAPPENDIX F 

Detailed Comment . on the Draft Report 

and OIG Response to the Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . .. FAPPENDIX G 

Endnotes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G­
EXECUTIVE SUMMAR 

PUROSE 

In this study, we assess me educational interventions that the Medicare-funded Peer 

Review Organizations (PROs) direct ' to physicians responsible for serious quality-ofcare problems. 

BACKGROUN 

A major objective of the PROs is to oversee the quality of care rendered to Medicare 

beneficiaries. In carrg out this objective, they have two major functions: (1) 

identif and confirm physicians and/or health care entities responsible for quality-ofcare problems, and (2) to direct follow-up actions to the responsible parties. 

In this report, we address the latter function. We examine educational interventions 

because the PROs rely heavily on them as corrective actions, and we focus on the 

most severe problems (those the PROs assign a Level III) because the PROs 

determined that those problems involved adverse effects on patients. For a sample of 

eight PROs, Vfe reviewed all such problems confirmed between January 1 and June 30 1990. We present our fidings around four key questions concerning the 131 

physicians identifed in our sample. 

FIINGS 

Who were the physician identied by the PROs as being responsible for serious

quaty-of-ce problems? 

Twen-eght peen of th physi were in genl practie, 60 peen were betwee 

45 an 64 yea o and 98 peen were ma. In th State in whih the physins practied 17 peen of aO physin.fwere in genl practe, 32 peen betwee 45 and 

64 an 83 peen ma 

At le th peen of th 131 physins ha more thn one quli-of-care proble id by the PROs. 

What kids of problems were they' responsible for? 

Eight peen of th physi were resnsle for ei (1) care resg in serus or

potell serus compliatins, or (2) abnorml dign figs le unesed

(3) both 

What kids of educational interventions did the PROs diec to thes physician? 

Th PROs diecte no edatinal inerentins to 14 peent of the physins. 
Amng th physi who di receie an edatina inenn, th PROs used lett 

call coures, and metigs mo oft 

Fort-two percent received a letter. 

Thirt percent received a telephone call. 

Twenty-two percent had to attend a continuing medical education course. 

Eighteen percent had to attend a meeting with PRO physicians. 

Hosls tyal were not involved wi or aware of the inenns. 

Fif-one percent of the hospitals were not inormed that a quality-of-care 

problem had occurred there. 

Eighty-eight percent of the hospitals where the quality-of-care problems 

occurred ha no part in the educational intervention. 

What conclusions ca we drw from the PROs' educational interventions? 

Th edatinql valu of th inentins is unerin 

The letters are tyically brief and contain more case summary than educational


material.


The calls are not documented enough to determne their content.


The available courses often do not address the specific quality-of-care problems


the PROs have identifed. 


The meetings with the PRO physicians have the most educational value 

according to both the PROs and the relevant literature, but were used in only 

18 percent of the cases we reviewed. 

Th PROs confrnt thee bas constrin in seekig to carr out efectie edatinal inenns. 

They have limited information on which to base their educational interventions. 

They perform oversight roles that inhibit their capacity as educators. 

They find that remedial medical education programs are seldom available. 
REMMATIONS 

The Health Care Financing Administration (HCF A) should ensure that the PROs 

initiate timely educational interventions in all confirmed Level III cases. 

The HCF A should issue a regulation or, if necessary, seek legislation mandating that 

for all confirmed Level III cases, the PRO share case information with the hospitals at 

which the problems occurred. That information should include the identity of the 

physician, the nature of the problem, and the tye of educational and other 

interventions imposed by the PRO. 

The HCF A should issue a regulation or, if necessary, seek legislation allowig and 

encouragig the PROs to involve the hospitals in the planning, conduct, and 

assessment of educational interventions in all Level III cases. 

The HCF A should instruct the PROs to give greater attention to personal meetings as 

an educational intervention and to explore ways of conducting one-to-one meetings 

between physicians with confirmed Level III quality-of-care problems and physician 

consultants. 

The HCF A should mandate that before directing an educational intervention to a 

physician in a level III case, the PROs take into account all prior quality-of-care 

problems they have identified concerning the physician during the life of the PRO 

contract. 

The HCF A should obtain and disseminate information on the effectiveness of PRO 

educational interventions. 

The HCF A should obtain and distribute to all the PROs the listing of 

focused/remedial education programs included in the national registry maintained by 

the American Medical Association. 

The Public Health Servce, through the Area Health Education Centers Program 

and/or the Agency for Health Care Policy and Research, should provide 

demonstration funding for the establishment and refinement of medical education 

programs that seek to enhance the clinical competence of physicians through 

individualized assessments and remedial education. 

COMMNT 

Within the Department of Health and Human Servces, we received comments from 

HCF A and PHS. The HCF A agreed with the fist recommendation, indicated that it 

would seek legal guidance concerning the second and third, offered to consider the 

fourth, suggested that the PROs' fourth scope of work addresses the fifth , and 

commented on more generalized education efforts concerning the sixh. 
In response to HCF A's comments, we changed the second and third recommendations 

so that they call for HCF A to issue a regulation or, if necessary, introduce legislation 

to further PRO-hospital interaction in Level III cases. We also amended 

the recommendation urgig PROs to take into account al prior quality-of-care 

problems before makig an educational intervention. In that recommendation, we 

specified that we were referrng to Level III cases and to problems identified by the 

PRO durig the life of its contract with HCFA 

The PHS, in relation to the comment we directed to it, suggested that the Area 

Health Education Centers (AHC) Program might be a more appropriate vehicle for 

funding demonstrations than the Agency for Health Care Policy and Research. 

Accordingly, we added the AHC program to our recommendation. 

Outside the Department, we received comments, generally supportive, from the 

American Association of Retired Persons (AAP), the American Medical Peer 

Review Association (AMRA), and the American Medical Association (AM). 

response, we made some minor clarifyng changes in recommendations and added a 

new recommendation callng for HCFA to keep the PROs informed of 

focused/remedial education programs included in the national registry of such 

programs maintained by the AM. 
INTRODUCTION 

PURSE 

The purpose of this study is to assess the educational interventions that the Medicarefunded Peer Review Organitions (PROs) direct to physicians responsible for serious 

quality-of-care problems. Toward tha end, we address four basic questions: 

1. Who were the physicians identified by the PROs as being responsible for serious 

quality-of-care problems? 

2. What kids of problems were they responsible for? 

3. What kids of educational interventions did the PROs direct to tnese physicians? 

4. What conclusions can we draw from the PROs' educational interventions? 

MEODOLOY 

Our methodology is based on a stratifed random sample of eight PROs (appendix A), 

for which we reviewed all confirmed Level III quality-of-care problems involving 

physicians identifed between January 1 and June 30, 1990. The Health Care 

Financing Administration (HCFA) defines such problems, which involved 131 

physicians, as involving "medical mismanagement with significant adverse effects on the 

patient. We supplemented our review by conducting discussions with admistrators 

and physicians associated with the eight PROs. 

BACKGROUN 

When the PROs were established in, 1982, their mission was almost completely focused 

on controllng Medicare costs. Today their mission is much broader and includes 

major responsibilty for overseeing the quality of care rendered to Medicare 

beneficiaries. The PROs carr out this responsibilty by reviewig inpatient medical 

records against standards of established professional practice. These reviews 

constitute about 15 percent of all Medicare admissions to hospitals. 

When the PROs identify what appears to be a quality-of-care problem, they conduct a 

second and sometimes third review. If at this point the PRO physician reviewers 

agree that a likely problem exists, the PROs invite the physicians and/or hospitals 

involved to provide more information. Upon further review, the PROs either confirm 

the problem or overturn their previous findings. 
As a part of this process, the PROs determine the degree of harm done the patient 

and, in accord with HCF A instructions, assign a severity level and weight value. 

Incidents involving no potential for harm are assigned a Severity Level I, with a weight 

of 1; those with a potential for harm are Level II, with a weight of 5; and those with 

actual harm are Level III, with a weight of 25. HCF A defies harm, or adverse 

effects, as prolonged treatment, readmission, impairment, disabilty, or death. Durig 

our sample time frame, the 53 PROs completed 1,055,964 reviews and identifed 9 620 

confed quality-of-care problems: 4 217 Level I, 4,711 Level II, and 692 Level III. 

At the end of each quarter, the PROs, in accord with HCF A's profilig requirements 

must total the weighted severity score for each physician they have identifed as havig 

one or more.quality-of-care problems.l The interventions the PROs then take are 

based on this score.2 For physicians responsible for a Level III problem, HCFA 

requires that the PROs invoke an educational intervention, conduct an intensifed 

review of subsequent hospital admissions, consider sharing the information with the 

medical licensure board, and consider recommending a sanction to the Offce of 

Inspector General (OIG).3 In addition, HCFA requires the PROs to notif the 

physicians of the confired quality-of-care problem in wrting and to take an 

additional intervention, such as requiring predischarge or preadmission approval. 

The educational interventions, which are the focus of this report, involve a range of 

possible actions. For example, they may involve coursework, suggested medical 

readings, or discussions with PRO physician advisors. These interventions may be 

taken singly or in any combination. The HCFA allows the PROs to determine the 

most appropriate tye of educational intervention for each physician. 

Overall, these educational interventions are a vital component of the PROs' quality 

assurance efforts. The HCF A mandates them for Le:vel III problems and for Level II 

problems with a score of 10 or more. And they far outnumber the more punitive 

interventions involving referrals to the medical licensure boards and the OIG. Yet 

little is known about the use or effectiveness of the educational interventions the 

PROs undertake. 
INDINGS


Who were the physici identied by the PROs as being responsible for serious

quaty-of-ce problems? 

Twen-egh peen of th physi were in gen prctie, 60 peen were betwee 

45 an 64 yea o~ an 98 peen were male In th State in whih the physins

prct 17 peen of aU physins were in gen prctie, 32 peen betwee 45 

64, an 83 peen ma 

We identifed the specialties4 for all but one of the 131 physicians in our sample. 

These 130 physicians represented 22 specialties which we grouped into four tyes: general practice, medical specialties, surgical specialties, and osteopathy (appendix C). 

In comparing their distribution among the four tyes with that of the non-Federals 

physicians in their States, we found more physicians responsible for serious quality-ofcare problems to be in general practice and less to be in medical specialties than 

would be the case if their distribution mirrored that of the 8 States (figure 1). The 

difference was statistically signficant. 

FIGUR 

PHYSICIAS WIH SERIOUS QUALY-OF-CARE


PROBLEMS AND ALL PHYSICIANS IN 


STATES, BY SPECIALTY 

Percent 

50% 

40% 

40% 

30% 

20% 

10% 

General Practice Medical Specialtes' Sureical Specialties Osteopathy 

Specialty 

Physicians, 8 States Phys. w/QOC Problems 

NOTE: N=79 581 non-Fedeal paJ-care physiia in Sta an N=130 physiia idfid by PROs as resnsible for a


confi Lel III qu-of-care proble an repned to HCFA for revs compled 1/1190-6/30190.


SOURCE: OIG/OEI ansi of do frm PROs; Amca Medial Asil Divin of Sur an Da Resources A.an


Medial Directorv: Physiia in th Unid Sta. 32 ed. (1990) an Physiia Chaacte an Disutn (1990); 


Amean Osteopath Asocian, Yearbook an Directorv of Osovath Physiia (1990).

We also compared the gender and age distribution of the physicians responsible for 

serious quality-of-care problems with the non-Federal physicians in their States. 

found a smaller proportion of female physicians than in the 8 States (2 percent 

compared with 17 percent), and we found fewer physicians either younger than 35 or 

older than 65 and more between 45 and 64 than in those States (figure 2). These 

differences in distribution were statistically signcant, too. 

FIGURE 2 

PHYSICIAS 1rH SERIOUS QUAL-OF-CARE


PROBLEMS AND ALL PHYICIAS


IN 8 STATES. BY AGE


Percent 

40% 

35% 32% 

30% 

25% 24% 

20% 

15% 

10% 

.. 35 35-44 45-54 55-64 65+ 

Age Category 

Physicians. 8 States Phys. "./QOC Problems 

NOTE: N=124 163 Irn-Fedeal phyia in State an N=130 phyia idfid by PROs as resnsle for confi 

Leel III quf-car proble an rert to HCFA for re compled 1/1190-6/30190. 

SOURCE: OIG/OEI tI of do from PROs Anan Medal Asian, Divin of Surey an Dat Resources Aman 

Medial Dictory: Physiia in th United State 32 etL (1990) an Phyia Chaacter an Disutn (1990); Marqu mw:s mw, Dirctory of Medal Speiais 24 ed. (1990); an Ame Osteopat Asocian, Yearbok an Diectory of 

Ostopath Phyia (1990). 

Finally, we compared the foreign medical graduate (FMG) distribution among these 

physicians and the non-Federal physicians in their States.s Thirty percent (35) of the 

physicians responsible for serious quality-of-care problems were FMGs, which reflects 

the proportion of FMGs in those States. 

At let th peen of th 131 physi ha more thn one quli-of-care proble id by th PROs. 

We asked staff at each PRO if they had identified any quality-of-care problems for 

these physicians prior to our sample time frame. Although the information was not 

always available, the PROs were able to identify 20 physicians (15 percent) who had 

confirmed quality-of-care problems prior to our sample time. Those problems

included Levels I, II, and III, and in one case, the PRO was recommending sanction. 

The PROs identified another 20 physicians (15 percent) who were responsible for 

additional9 quality-of-care problems during the sample time or identifed in intensifed 

review. 

What kids of problems were they responsible for? 

Eight peen of th physi wer resnsle for ei (1) care resg in serus or 

pote serus compliatins or (2) abnorm dign figs le unesed 

(3) both 

Fort percent (52) of these physicians provided care that resulted in serious or 

potentially serious complications. to For example, one problem involved an attempt 

to repair a patient's broken femur with a rod implant. The rod implant split the bone 

therefore requirig a wie wrap. The wie wrapped the artery and nerve instead of 

just the bone. Despite the patient's symptoms of vascular impairment, corrective 

surgery was delayed and the patient died of sepsis. 

Twenty-three percent (30) of these physicians provided care that left abnormal 

diagnostic findings unaddressed. One such problem involved a patient suffering a lowgrade fever for three days prior to discharge and whose white blood cell count was 

high, indicating infection, on the day of discharge. Eight days later the patient was 

readmitted because of the infection. 

Seventeen percent (22) of these physicians provided care that failed both screens. For 

example, one problem involved a surgeon s premature discharge of a patient after a 

'below- the-knee amputation. The stump was open and draing at the time of 

discharge and the patient was readmitted with an infected and painl stump. The 

surgeon performed a debridement and closure, but they were ineffective, and the leg 

was fially amputated above-the-knee. The PRO noted that the patient's complicated 

postoperative period was a result of the inappropriate below-the-knee amputation. 

The remaing 20 percent of the physicians were responsible for various other 

problems such as medication errors and nosocomial infections. 

What kids of educational interventions did the PROs diec to these physician? 

Th PROs diected no edatinal inenns to 14 peen of th physi. 

The PROs' response to the 131 physicians responsible for serious quality-of-care 

problems was multi-faceted (appendix E). They sent notifcations and conducted 

intensified reviews on the hospital admissions of all the physicians.u They also took 

various other interventions, ranging from predischarge screening to preoperative 

consultation, against 44 percent of the physicians. And we saw documentation that 

they considered referrg 53 percent of the physicians to the OIG for sanctioning and 

39 percent to the State licensure boards. These considerations, however, led to few 

actual referrals, with only two to the OIG and three to the boards. 
;:;:; ;:;:; ;:; ;:;:; ;:;:;:;:;:;:;:;:; ;:;:; ;:: ;: ;:;:;:;:;:; ;:::::; ;:;:;:; .. ;:;:; ;:::; ::::::: 

For the educational interventions, which provide the focus of this study, it is strikig 

that the PROs directed no such interventions to 14 percent (18) of the 131 physicians 

found to be responsible for serious quality-of-care problems (figure 3). Ths omission 

occurred despite HCF A's requirement that an educational intervention be directed to 

each such physician. Like the others, these 18 physicians each received the 

notifcation of a confrmed quality-of-care problem from the PRO, and each was 

subject to intensified review (appendix E). 

FIGURE 3 

NUER OF EDUCATIONAL INVEONS 

PROs IMSED PER PHYSICI 

;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;TWiJ:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:;:; 

None 

NOTE: N=131 physiia idfied by PROs as resnsible for Q confi Lel III Il b/e an reponed to 

HCFA for revs completed 11/90-6130/90. 

SOURCE: OIGIOEI ansi of da from PROs 

These 18 physicians involved 5 of the 8 PROs in our sample. For eight of the 

physicians, the PROs' records offef( d no documentation on why the educational 

interventions were not made. For seven of them, al involvig one PRO, the PRO 

deferred the interventions for many months so that it could undertake retrospective 

medical reviews to ascertain whether the quality-of-care problems were isolated or 12 The PROs did not pursue an educational intervention for two part of a pattern.


physicians because they were recommending sanctions 13 and for one such an 

intervention was unnecessary because the physician retired. 

Amng th physins who di receie an edatinal inenn, the PROs used lett 

call coures and metigs mo oft 

Fort-two percent received a letter. 

Thirt percent received a telephone call. 
Twenty-two percent had to attend a continuing medical education course. 

Eighteen percent had to attend a meeting with PRO physicians. 

The PROs used these four educational interventions alone and in combinations. 

Physicians responsible for serious quality-of-care problems usually received one 

educational intervention (figure 3), and that intervention most often was a letter. The 

most common combination was a letter and a phone call, usually from the medical 

director or, in some cases, a physician adviser or a quality assurance committee 

member. 

The PROs required about one of every five physicians responsible for a serious 

quality-of-care problem to attend a continuing medica education (CME) course. The 

CME requirement ranged from as few as 12 hours to as many as 50. In every case 

the PRO approved the course syllabus and required proof of attendance. 

The meetings imposed as an educational intervention usually involved the physician 

attending a regularly scheduled meeting of the quality assurance commttee at the 

PRO to discuss the quality-of-care problem. The PRO medical director, peer 

physicians, and nurse reviewers usually staff these committees. 

The PROs' inventory of educational interventions contains more than the four noted 

above. For example, the PROs occasionally suggested medical readings and, in one 

case, required the physician to attend a refresher residency. 

Hosit typicall were not involved wi or aware of the inenns. 

Fift-one percent of the hospitals were not informed that a quality-of-care 

problem had occurred there. 

Eighty-eight percent of the hospitals where the quality-of-care problems 

occurred had no part in the educational intervention. 

According to HCF A policy, the PROs 
 may release physician-specific inormation about 

confrmed quality-of-care problems to hospitals where the problem occurred without a 

request and must release it upon the hospital's request. Thee of the eight sample 

PROs routinely inform hospitals that a physician has been notified of a confrmed 

problem. The others have informed the hospital in only a few cases, citing both 

confdentiality concerns and HCF A's policy as reasons. 

Usually, the PROs that inform the hospitals do so by sending a copy of the physician 

notice to the hospital's quality assurance committee, relevant department chair, and/or 

designated liaison. The PRO would not necessarily know if the hospital took any 

action upon receiving the notice, or if the hospital already knew about the problem. 
One PRO not only informed hospitals of problems, but also involved them in the 

educational interventions. In fact, this particular PRO was responsible for 23 of the 25 

cases in which the hospital was involved in the educational interventions. The 

involvement usually included a discussion of the quality problem between a hospital 

physician (for example, the chair of the quality assurance committee or relevant 

department) and the physician responsible for the problem. In some cases, they 

discussed the problem during grand rounds or a morbidity and mortality committee 

meeting. 

For 6 of the 131 quality-of-care problems, the PROs' interventions resulted in changes 

in hospital policies or protocols that could prevent other quality-of-care problems. For 

example, one problem involved the delayed treatment of an elderly patient's severe 

pulmonary edema resulting in the patient s death. The PRO determned that both the 

attending physician and the surgical resident were responsible for the problem. The 

PRO notifed the hospital of the problem, required both physicians to attend the 

PRO' s quality assurance meeting, and issued a first sanction notice for one physician. 

In addition, the PRO prompted the hospital's implementation of new policies for 

geriatric consultations and resident training in geriatric medicine. 

What conclusions ca we drw from the PROs' educational interventions? 

Th edatinal valu of the inenns is unerin 

The letters are tyically brief and contain more case summary than educational 

material. 

The calls are not documented enough to determine their content. 

The available courses often do not address the specific quality-of-care problems 

the PROs have identifed. 

The meetings with the PRO physicians have the most educational value 

according to both the PROs and the relevant literature, but were used in only 

18 percent of the cases we reviewed. 

None of the eight sample PROs had formally assessed the effectiveness of their 

educational interventions.14 Some representatives of the PROs, however, indicated 

that these interventions were important not only for the physicians involved but for 

other physicians in the State. In this context, they sometimes referred to a sentinel 

effect, whereby physicians change their practice because of the expectations and 

oversight activities of the PROs. 

lS In its recent report Medicare: A Strategy for Quality Assurance the Institute of 

Medicine (10M) reviewed the evolving research on educational interventions involving 

physicians. On the basis of this research, it suggested five elements that must be 
present if educational interventions are to have much effect in changig physician 

behavior. These elements seldom appear to be associated with PRO interventions. 

First, the physician must accept that he or she needs to change. The PROs reported 

to us that physicians often engage lawyers to respond to a PRO as soon as they 

receive a notice of a potential quality-of-care problem. In fact, one PRO offcial said 

the medical society in its State identified a particular law firm physicians use when 

contacted by a PRO. In reviewig the case fies for this PRO and others, we saw 

much contentious correspondence between the physicians, their lawyers, and the 

PROs, and few indications that the physicians accepted the PROs' conclusions. 

The second element is that the content of the education must be specifc to the area 

needing change. PRO offcials often indicated that they could not fid courses that 

were suffciently responsive to a physician s particular educational need. Ths problem 

is exacerbated in rural areas where access to medical semiars and conferences can be 

lited. 

The remainig three elements focus on a personal meeting with the physician. 

Physicians, reports the 10M, are likely to respond most positively to an educational 

intervention when it (1) is offered in a personal meeting, (2) is conducted one-to-one 

16 Although most PRO offcials and (3) is with a trusted and respected colleague.


reported believing that meetings are effective in changing physician behavior, fewer 

than one in five of the physicians in our sample had had an intervention that involved 

such a meeting. Moreover, those who did attend such a meeting often brought their 

lawyers and almost always found themselves confonting a number of PRO physicians 

.' rather than a single, trusted colleague. That is not to suggest that the meetings had no 

, educational value, only that according to the literature the setting did not appear to be 

conducive to providing the maxmum educational benefit. 

Th PROs confront thee bas constrin in seekig to cany out efectie edatinal inenns. 

They have limited information on which to base their educational interventions. 

The PROs usually base their interventions on one incident of care in 

one three-month period. 

The PROs' fies usually don t identify the physician s specialty, 

, certification status, medical school, or other information about 

credentials. 

The PROs rarely know about medical board or hospital actions taken 

against the physician.


The PROs cannot query the National Practitioner Data Bank about 

specific physicians. 
The PROs tyically conduct a thorough inquiry in documenting a serious quality-ofcare problem. However, the PROs act in a more restricted manner in determg 

what kid of educational. intervention to take once the problem is documented. Ths 

is in large part because the PRO physician advisors who decide on the intervention 

usually make their decision on the basis of one incident of care in one three month 

period, in accord with HCF A's quarterly profiing requirement. At some PROs, they 

do not review their own data for previous quality-of-cae problems involvig a given physician. They are also unlkely to know if the State medical board, a hospital, or 

other health care entity has taken or is considerig taking action against the 

physicianP And Federal law stil does not allow the PROs access to the National 

Practitioner Data Bank, which would identif any adverse actions taken by medical 

boards or health care entities such as hospitals and any malpractice payments involving 

the physician.


They perform oversight roles that inbit their capacity as educators. 

In their oversight roles, PROs review the medical practice of physicians, identify those 

physicians responsible for quality-of-care problems, and then impose certain corrective 

actions. They must do this in accord with due process safeguards and myrad formal 

requirements imposed by the Federal governent. Understandably, the interactions 

between the PRO offcials and these physicians often become adversarial, as the 

physicians express concerns about the accuracy of the PROs' judgments and/or the 

implications for their medical practices. 

Amid such interactions, it is difficult for the PRO offcials and the physicians with 

./ confrmed quality-of-care problems to relate to one another in an essentially 

, educational sense. The PROs impose a certain threat to the physicians, however 

much they might attempt to deemphasize it. This threat limits, but does not 

altogether preclude, their opportunity to serve as medical educators. 

They fid that remedal medca education progr are seldom avaable. 

Most PROs are unable to refer a physician with a serious quality-of-care problem to 

an educational program that offers an intensive and individualized response to the 

physician s needs. The limited availabilty of such programs, a number of PRO 

offcials report, signficantly restricts what they can accomplish through their 

educational interventions. 
.

RECOMMENDATIONS


The physicians we focused on in this report were found responsible for "medical


mismanagement with signficant adverse effects on the patient." The educational


interventions we reviewed were imposed to help these physicians improve their


medical management skills and avoid the need for corrective actions of a punitive


nature. This educational orientation is central to the purpose of the PRO program. 

Yet, as the fidings in this report indicate, the educational efforts of the PROs appear 

to fall well short of their potential. We urge HCFA to give major attention to 

correcting tJ:s deficiency. Toward that end, we offer seven recommendations directed 

to HCFA We also present one recommendation to the Public Health Servce. 

TI HETI CAR FIANCIG ADMISTTION 

HCFA shoul ene tht th PROs inte tily edatinal inenns in aU
 confi Leel m caes.
 Th 

The PROs should be held accountable for carrng out the educational interventions 

currently mandated in all Level III cases unless, of course, the physician voluntariy 

surrenders his/her medical license. In our sample, 14 percent of the cases involved no 

such intervention at least six months after the PRO had confirmed a Level III qualityof-care problem. 

/ Th HCF A shoul is a regtin or, if necesary, seek lelatin mandtig th for 

aU confi Leel cases, th PRO share case informtin wi th hoitls at whih 

th proble ocCUed Tht informtin shoul inlu th id of th physi th natie of th proble an th type of edatina and oth inenns impoed by 

PRO. 

HCF A shoul is a regtin or, if neesary, seek lelatin aOowig and 

enourgig th PROs to involve th hols in th planng, condt, and ases Th 

of edatina inenns in aU Leel m cases. 

Through their own quality assurance efforts, hospitals can and in some cases do play 

an important role in helping PROs achieve their educational objectives. The PROs, it 

would appear, could take much greater advantage of this complementary role. Yet 

for confidentiality and other reasons, some PROs are reluctant to inform hospitals 

about quality-of-care problems and any interventions directed to physicians, and even 

more so to involve them in the conduct of the educational efforts and in the ongoing 

assessment of these efforts. By carrng out the above recommendations, HCF A could 

help correct this situation. 
HCFA shoul int th PROs to gie greate attn to peona metigs as an edatna inenn an to exlore ways of condg one-to-one megs betwee Th 

physi wi confi Leel m quli-of-care prble and physin consnt. 

In our sample, only 18 percent of the educational interventions involved a meeting 

with PRO physicians. And even when a meeting was held, the educational value was 

uncertain. A meeting tyically involved a number of PRO offcials, with an attorney 

often accompanying the physician, therefore resemblig a hearg more than an 

educational exchange. We urge that HCFA and the PROs examie ways of making 

more effective use of one-to-one personal meetings as an educational tool and in so 

doing take account of the research findings concerning how physicians learn. 

Th HCFA shoul mate tht before diectig an edatina inenn to a 

physi ina Leel m cas th PROs ta in accoun al prir qu-of-care 

prble th hae id concerg tht physi dug th lie of th PRO 

contct 

PRO physician advisors often lack suffcient information about a physician s practice 

deficiencies to craft a well-suited educational intervention. Ths can be corrected by 

obtainig more inormation from "outside" sources, such as State medical boards, but 

also from the PRO itself. At a minimum, we believe that the PRO, in developing an 

educational intervention for a physician, should review any prior quality problems, be 

they Level I, II, or III, that the PRO itself has identified for that physician over the 

term of the PRO contract. This would help identify if there is a pattern of medical 

, practice problems that the PRO should address in its educational effort. 

Th HCFA shoul obtain and diemte informtin on th efectien of PRO 

edatinal inenns. 

Do these interventions result in changed physician behavior? What tyes of 

interventions are likely to be most effective, under what conditions and in what 

combinations? Are medical education efforts sometimes relied upon to address 

problems that in essence are unrelated to medical knowledge or practice skis? To 

help answer such questions, HCF A should require that PROs prepare a wrtten 

assessment of the effectiveness of each Level III educational intervention. It should 

also support research efforts on the relative effectiveness of diferent educational 

actions directed to physicians responsible for poor medical care. By doing so, it could 

help the PROs identify and take advantage of the lessons learned from their 

considerable experience in undertaking educational interventions. 

Th HCFA shoul obtain and ditrute to aU th PROs th litig offocedlreml 

edatin proms inlu in the natinal regtr mainin by the Aman Medal 

Asoctin. 

The number of such programs is limited, but those that are available can be an 

extremely helpful resource for physicians whose medical knowledge or skis are 
deficient. The HCF A should assure that the PROs are fully aware of the programs 

, that do exist and consider them when meeting with physicians to discuss appropriate 

educational activities. 


TH PUBUC HETI SERVICE


Th Puli Hea See, thugh th Area Healt Edatn Ce Pr and/or

th AgenJor Healt Ca Poli and Reseah, sho prvi denstrn ftg for th eslihm and re of meal edn prms tht see to ene 

th cli comptee of physi thug in ases and rem edtin. 

Individualized assessment and education programs, such as Ontario s Physician 

Enhancement Program, can serve as an effective approach for addressing medical 

practice deficiencies. Yet, with few such programs available in the United States 

PROs seldom have the option of referrg a physician to one as part of an educational 

intervention. The American Medical Association has encouraged State and local 

medical societies to assist in the development of such programs.20 The Public Health 

Servce, through demonstration funding, can assist by using some of its demonstration 

funds to help determne the tye of physician enhancement programs likely to be most 

effective. 
COMMENTS ON THE DRAFT REPORT


Within the Department of Health and Human Servces, we received comments from 

the Health Cae Financing Administration (HCF A) and the Public Health Servce 

(PHS). In addition, we received comments from a number of private organiations. 

These included the American Association of Retired Persons (AA), the American 

Medical Peer Review Organition (AMRA), and the American Medical Association 

(AM). In appendix F, we present the full comments offered and our response to 

them. 

Our second and thid recommendations calling for the PROs to share more 

inormation about Level III cases with hospitals and to involve hospitals in the

plang and conduct of the educational interventions generated the most attention. 

The PHS, AA, and AMRA expressed support for such action. The HCFA, 

which the recommendation was directed, indicated it would seek guidance from its 

general counsel to determne what if any action could be taken. 

In view of the legal uncertainty and the vital importance of these recommendations to 

the future effectiveness of the PROs' educational efforts in Level III cases , we have 

changed them so that they call for HCF A to issue regulations or, if necessary, seek 

legislation to foster closer PRO-hospital interactions in Level III cases. 

In our fifth recommendation, callig for PROs to take into account all prior quality-ofcare problems before making an educational intervention, we made two changes to 

clari that we were referrg to Level III cases and to prior problems identified by a 

" PRO durig the life of its contract with HCFA We agree with AMRA that the 

PROs should "maintain a capacity to profie quality-of-care problems by individual 

practitioner(s) over the term of a PRO contract." 

In response to the AM' s comment about its national registry on focused/remedial 

education programs, we added a recommendation urging HCF A to see that all PROs 

are kept informed about such programs. For some physicians, such programs can 

serve as a crucial educational resource. 

Finally, with respect to our recommendation callng for PHS to provide demonstration 

funding for such programs, we added the Area Health Education Centers Program as 

a potential source for such funding. This was in response to comments from PHS 

addressing the potential relevance of that program. 
APPENDIX A


MEODOLOICAL NOTE


We reviewed all confirmed Level III quality-of-care problems involving physicians 

identified by eight PROs and reported to HCF A for reviews completed between 

January 1 and June 30, 1990. We selected the eight PROs by dividing all PROs into 

three strata, according to their volume of confed Level III problems. We then 

randomly selected 4 PROs from the high (20 or more problems) and 4 from the 

medium (6-19 problems) volume strata. Those 2 strata represent 30 PROs and 86 

percent of all the confed Level III quality-of-care problems reported durig our 

time frame. We excluded the PROs with fewer than six confrmed Level III qualty 

problems due to the cost of including them and their lesser experience with 

interventions. 

We made site visits to six of the eight PROs, collecting our information by phone and 

mail for the others. We reviewed the PROs' records for each of the 131 physicians 

identifed by those 8 PROs (see appendix B for a sample overvew). Those 131 

physicians account for 22 percent of the confirmed Level III quality-of-care problems 

identifed by the 30 PROs in those 2 strata, and 19 percent of the confrmed Level III problems in all PROs. 

Durig our review we recorded physicians' names , a description of the quality-of-care 

problem, the name of the hospital, and the interventions taken by the PROs. We also 

recorded the generic quality screen failures for each case, as a way to group the 

problems. Using a discussion guide, we went over the intervention process with each 

PRO' s medical director. In some cases, the chief executive offcer, physician 

reviewers, and the quality review director participated. 

We collected the physician profile c4ta from the data bases and publications of the 

American Medical Association and the American Osteopathic Association. 

We used Chi-square comparison of proportions tests to compare the distribution of 

the 131 physicians with non-Federal physicians in the 8 States by specialty, age 

gender, and foreign medical graduate status. 

A ­

APPENDIX 


SAMLE OVEVIW 

CONFIRMED LEVEL III N USED 

QUALIT-OF CAR CASES FOR 

PROBLEMS REPORTED REVIEWED MOST 

TO HCFA, 1/1/90- *TOTAL CASES WIIN SCOPE ANALYPRO 6/30/90 REVIEWED OF INSPECTION SES

6*** 

10  

' 47** ** 

/ 8


TOTAL 161 158 135 131 

* Some of these PROs identifed c&ses not reported to HCF A. 

** We omitted cases from our scope for the following reasons: 6 problems occurred 

in a setting other than inpatient, 4 problems involved the provider rather than the 

physician as the responsible party, and 13 problems were either overturned or reduced 

to a lesser severity level. 


*** In this PRO, two physicians were each responsible for two quality-of-care 

problems, or cases, durig the sample time. To avoid double counting the physicians 

we omitted one case for each from our analysis. 

**** In each of these two PROs, one physician was responsible for two quality


problems, or cases, during the sample time. To avoid double counting these


physicians, we omitted one case each from our analysis.

APPENDIX C


SUMY OF PHYSICI PROFl DATA 

Followig are summary data of the 131 physicians identifed by 8 PROs as being 

responsible for confied Level III quality-of-care problems that were reported to 

HCFA for reviews completed between January 1 and June 30, 1990. Our sources for 

this data include: 

The 8 PROs. 

American Medical Association American Medical Directory: Physicians in the 

United States. 32nd ed., Division of Survey and Data Resources, Department of 

Physician Data Servces, 1990. 

American Medical Association, Physician ProfIe Data, Division of Survey and 

Data Resources, Department of Physician and Data Servces, correspondence 

2/13/91 and 2/22/91. 

American Osteopathic Association Yearbook and Directory of Osteopathic 

Physicians. 1990 ed. 

Marquis Who s Who Directory of Medical Specialists, 24th ed., Wilmette, IL 

1990. 

C - 1

SUMY OF PHYSICI PROFl DATA


GENER 

Male 

Female 

Unkown 

AGE (in 199) 

c:35


35­


45­


55­


65+


Unkown 

SPECITY 

General. and Family Practice 

Medical Specialties 

Surgica Specialties 

Osteopathy 

Unkown 

CETICATION STATUS 

Certifed 

Not Certifed 

(excludes 11 osteopaths) 

FRQUECY PERCE 

110 98% 

112 100% 

130 100% 

28% 

130 100% 

65% 

120 100% 

FOREIGN MEICAL GRAUATE 

Yes 30% 

(excludes 11 osteopaths) 

Unkown 

117 100% 

C - 2

DETAI ON SPECITY CATEGORITION 

SPECITY CATEGORITION NUER OF PHYSICIS 

GEN PRACfCE 

General Practice 

Family Practice 

MEICAL SPECITI 

Internal Medicine 

Cardiovascular Diseases 

Medical Oncology


Nephrology


Pulmonary Diseases


Anesthesiology


Geriatrics


Hematology


Neurology


Pathology


Rheumatology


SURGICAL SPECITI 

General Surgery


Orthopedic Surgery


Urology 

Neurosurgery 

Thoracic Surgery


Obstetrics and Gynecology 

Otolarygology 

Vascular Surgery


OSOPATH 

SPECITY UNOWN 

TOTAL 

SEROUS QUAL -OF-CAR 

PROBLE 

27* 

130 

131 

lnc1udes three surgical residents 

C - 3

APPENDIX D


GENC QUAL SCRS


Below we provide HCFA' s defitions from the third Scope of Work for the inpatient 

hospital generic quality screens. Following the definitions, we provide a summary of 

the screens failed by the 131 physicians the 8 PROs identifed as responsible for

confed Level III quality-of-care problems reported to HCF A for reviews completed 

between January 1 and June 30, 1990. 

DEFONS OF TH INATI HOSPITAL GENC QUAL SCRS 

1. Adequacy of Discharge Planning 

No documentation of discharge planning or appropriate follow-up care with 

consideration of physical, emotional, and mental status needs at time of 

discharge. 

2. Medical Stabilty of the Patient 

Blood pressure within 24 hours of discharge (systolic less than 85 or 

greater than 180; diastolic less than 50 or greater than 110). 

Temperature within 24 hours of discharge greater than 101 degrees 

Fahrenheit (38.3 Centigrade) oral, greater than 102 degrees Fahrenheit 

(38.9 Centigrade) rec 

Pulse less than 50 (or 45 if the patient is on a beta blocker), or greater 

than 120 within 24 hours of discharge. 

Abnormal diagnostic findings which are not addressed and resolved or 

where the record does not explain why they are not resolved. 

Intravenous fluids or drugs after 12 midnight on the day of discharge. 

Purulent or bloody drainage of wound or open area within 24 hours 

prior to discharge.


D - 1

3. Deaths


During or following any surgery performed during the current admission. 

Following return to intensive care unit, coronary care or other special


care unit within 24 hours of being transferred out.


Other unexpected death.


4. Nosocomial Infection 

Hospital-acquired infection. 

5. Unscheduled Return to Surgery 

Within the same admission for same condition as previous surgery or to 

correct operative problem. 

6. Trauma Suffered in the Hospital 

Unplanned surgery which includes, but is not limited to, removal or 

repair of a normal organ or body part (i.e., surgery not addressed 

specifcally in the operative consent) 

Fall 

Serious complications of anesthesia 

Any transfusion error or serious transfusion reaction 

Hospital-acquired decubitus ulcer and/or deterioration of existing 

decubitus 

Medication error or adverse drug reaction (1) with serious potential for 

harm or (2) resulting in measures to correct 

Care or lack of care resulting in serious or potentially serious 

complications 

7. Optional Screen


Medication or treatment changes (including discontinuation) within 24 

hours of discharge without adequate observation 

D - 2 
SUMY OF QUAL-OF CAR PROBLE PROFI DATA: 

NUER OF PHYSICIAS FAIG GENC QUAL SCRS 

DISCHGE PLAG SCR


Fail


Pass


Unkown


MEICAL


STABIL SCRS


Fail


Pass


Unkown


DEATI SCRENS


Fail


Pass


Unknown 

NOSOMI


INCTON SCR


Fail


Pass


Unkown


UNSCHULD
 RE 

SURGERY SCREN 

Fail


Pass


Unkown


FRQUECY PERCE


120 

129 100% 

43% 

129 100% 

15% 

109 

129 100% 

123 

129 100% 

121 

129 100% 

D - 3

TRUM SUF 

IN TH HOSPITAL 

FRQUECY PERCE 

Fail 59% 

Pass 41% 

129 100% 

Unkown 

OPTONAL OR 

PROS' OWN SCRS 

Fail 18% 

Pass 106 

129 100% 

Unknown 

D - 4

APPENDIX E


SUMY OF INVEON PROFI DATA 

Followig are summary data of the interventions the 8 PROs directed to the 131 

physicians identified as responsible for confirmed Level III quality-of-care problems 

that were reported to HCFA for reviews completed between January 1 and June 30 

1990. 

E - 1

SUMY OF QUAL INVEON PROFI DATA


INVEON


NOTCATION 

Imposed 

EDUCATIONAL INVEON 

Imposed 

Not Imposed


INSIF 

REVIW 

Imposed 

OTH INVEONS 

Imposed 

Not Imposed


SHAG 

UCESUR BODIE 

Considered 

Not Considered


Shared 

SANCTON 

Considered 

Not Considered


1st Notice Issued


Sanctioned


FRQUECY PERCE 

131 100% 

113 86% 

14% 

131 100% 

131 100% 

44% 

131 100% 

39% 

131 100% 

53% 

131 100% 

E - 2 
SUMY OF EDUCATIONAL INVEON PROFI DATA


INVEON 

Imposed 

Not Imposed


PHONE CAl 

Imposed 

Not Imposed


COUREWORK 

Imposed 

Not Imposed


MEG WI 

PRO PHYSICIS 

Imposed 

Not Imposed


SUGGESTE 

REING 

Imposed 

Not Imposed


REHE 

REIDENCY 

Imposed 

Not Imposed


METIG WI HOSPITAL 

PHYSICIS 

Imposed 

Not Imposed


FRQUECY PERCE 

42% 

113 100% 

30% 

113 100% 

22% 

113 100% 

18% 

113 100% 

110 

113 100% 

112 

113 100% 

22% 

113 100% 

E - 3 
APPENDIX 

EfAn COMM ON TH DRA REORT OIG REPONSE TO TH COMM 

In this appendix, we present in full the comments on the draft report offered by the 

Health Care Financing Admistration (HCFA), the Public Health Servce (PHS), the 

American Association of Retired Persons (AA), the American Medical Peer 

Review Association (AMRA), and the American Medical Association (AM). 

each case, we also include our response to the comments. 

F ­

&. 

Health Care 

DEPARTME!\T or HEALTH HVMAN SERVICES	 Financing Administration 

"."..a Memorandum 

.NOV I 8 1991 Date 

From	 Gai R. Wilensky, Ph.D. 


Adminstrator


Subject	 OIG Draft Report - "Educating Physicians Responsible for Poor Medical Cae: A


Review of the Peer Review Organiztions' Effort," OEI-Ol-89-0020


Inpector General


Ofce of the Secretary


We have reviewed the subject draft report which assesses the educational 

interventions the peer review organitions (PROs) direct to physicians responsible 

for serious quality-of-care problems. The report found that the educational vaue 

PROs' interventions is uncertain and that the PROs face basic constraints that liit 

the effectiveness of these interventions. 

The report addresses six recommendations to HCF Our comments on these 

recommendations, as well as general comments on the report are attached. 

Thank you for the opportunty to review and comment on this report. Please 

advise us whether you agree with our position on the report s recommendations at 

your earliest convenience. 

Attachment 

F ­

Comments of the Health Cae Financig Administration 

Draft Report. "Eucating Physician Responsible 

for Poor Medical Care: A Review of the Peer Revew 

Organizations' Effort." OEI-Ol-89-O20 

Recommendation 

The HCF A should ensure that the PROs intiate tiely educational interventions in 

al confed Level III cases, unless the physician surenders bi/her medica license. 

esponse 

We concur with ths recommendation. We require peer review organtions 

(PROs) to intiate interventions withi 30 days afer the close of the review quarer, 

uness the error is so egregious that it warants imediate intervention. We 

evaluate the performance of PROs using the Peer Review Organtion Monitorig 

Protocol and Trackig System (PROMPTS). When we perform the PROMPTS 

evaluations, we review to determe whether educational interventions are 

implemented as directed. PROs are requied to submit correctie acton plan 

which are monitored closely when PROMP identies deficiencies in PRO 

implementation of educational efforts. In the nex PROMP review, we wi pul a 

focused sample of Level III caes to ensure that educationa interventions were 

properly intiated. 

Recommendation 2


The HCFA should mandate that for all confed Level il cases, the PRO share 

case information with the hospitals at which the problems occured. That 

inormation should include the identity of the physician the nature of the problem, 

and the tye of educational and other interventions imposed by the PRO. 

Response 

We wi confer with the Offce of the General Counel (OGC) in order to obtai 

more specific guidance as to what inormation concernng educational interventions 

can be shared with hospitals. 

F ­

Page 2


Recommendation 3


The HCF A should encourage the PROs to involve the hospitals in the planng and 

conduct of the educational interventions. 

esponse 

As previously stated, we need to confer with OGe on the issue of sharg 

inormation on educational interventions with hospitals in order to determine 

whether we can implement this recommendation. In addition, we believe that many 

spitals (e.g., small hospitals) are not equipped to perform such fuctions. 

Recommenqation 4


The HCF A should instruct the PROs to give greater attention to personal meetings 

as an education intervention and to explore ways of conducting one-to-one meetings 

between physicians with confmned Level III quality-of-cre problems and physician 

consultants. 

Response 

We are currently revewing options for improvig our quality intervention plan and 

wil consider this recommendation in conjunction with other appropriate changes. 

Recommendation 5


The HCF A should mandate that before directing an education intervention to a 

physician, the PROs take into account all prior quality-of-care problems they have 

identifed concernng the physician. 

Response 

The PROs take prior history into account when decidig what intervention to take. 

The scope of work for the fourth contracting cycle claries that the PRO is to take 

into account prior history when deciding upon the appropriate intervention. 

F ­

Page 3


Recommendation 6


The HCFA should obtain and disemiate inormation on the effectiveness of PRO 

education interventions. 

Besponse 

HCFA is commtted to a strong progr of education and inormation 

dissemiation among the PROs and though the PROs to the communty. The 

specifc recommendation to dissemiate inormation on the effeceness of PRO 

educational interventions wi be reaed with the implementation of a program of 

epidemiologic evaluation and oversight though the PROs. Under the scpe 

work for the next round of contract with the PROs, there is signcat emphasis 

on education and feedback to the heath cae provders and practitioners on 

pattern of practice and the associated outcomes of cae. 

Genera) Comments 

Page i - OIG's background statement implies that the PROs' two major 

functions are policing activties. We suggest th pargraph be rewrtten 

to emphasize that the priar responsibilty of the PROs is to ensure 

Medicare beneficiaries receive good quaty cae. 

Page 10 - OIG indicates that the PROs have lited inormation and that 

the PROs rarely know about medica board or hospita actons taen 

against physician. We agree that th is tre. Although OIG wants the 

PROs to share inormation freely with the medica boards and hospita, 

there is no companion recommendation that these other entities share 

information with the PROs. In the futue, PRO accss to the National 

Practitioner Data Ban wi help in th regard. 

F ­

.I 

OIG REPONSE TO HCFA COMM 

We respond as follows to HCFA's comments on each of the recommendations: 

Recmmendation 1: We welcome HCFA' s follow up to ensure that educational 

interventions are properly initiated. 

Recmmendation 2: In view of HCF A' s reservation about the legal basis of the 

recommendation as stated in the draft report, we have modified it to cal for the 

necessary regulatory or statutory changes. We urge that HCFA move quickly in 

carrg out this recommendation because it has a major bearig on the effectiveness 

of PRO educational interventions in Level III cases. 

In this context, we suggest that HCF A take into account that a close workig 

relationship with hospitals (and their own qualty assurance commttees) supports the 

continuous quality improvement principles which HCF A is embracing for the PRO 

program. By involvig the hospital in the intervention process and by keeping the 

hospital regularly informed of educational interventions taken against its physicians 

the PRO would be contributing to a more collegial process that involves more 

effective use of data concerning the quality of care. 

We also suggest that HCFA take note of the support for this recommendation 

expressed by the Public Health Servce, the American Association of Retired Persons 

and the American Medical Peer Review Association. The American Medical 

Association did not respond directly to the desirabilty of the recommendation, but did 

, emphasize that there should be strict liits to any educational activities undertaken 

directly by the PROs. Our recommendation is made in recogntion of such limits and 

of the major contributions that hospitals can make in assisting physicians found to 

have serious quality-of-care problems. Indeed, one of the PROs in our sample was 

working very closely with hospitals, just as we call for in the recommendations. 

Recmmendation 3: Our response concerng HCF A's comments on the above 

recommendation also apply to this recommendation. Hospitals can and should be 

major participants in crafting and overseeing educational plans for physicians who 

have been responsible for serious quality-of-care problems. We urge HCFA and the 

PROs to move quickly in this direction. 

Recmmendation 4: We regret that HCFA did not offer a more definitive response 

to this recommendation. One-to-one meetings, as research findings indicate, can lead 

to more effective educational interventions. We urge HCFA to identify ways to 

incorporate such meetings into the educational process in Level III cases. 

Recmmendation 5: HCF A indicates that the scope of work for the fourth contract 

PRO is to take into account prior history when deciding upon cycle will clarify that the 


an educational intervention. Such language moves in the direction we call for, but is 

F ­

not suffciently precise. We urge that HCFA follow the suggestion offered in 

AMRA' s response to us and require that the PROs "maintain a capacity to profile 

quality of care problems by individual practitioner(s) over the term of a PRO contract 

and not just for consecutive quarters which is the mandate at present." Such an 

approach would help identif any pattern of quality problems and would allow for 

educational interventions more appropriately tailored to a physician s needs. 

(Accordingly, we have specifed in our recommendation that before fashioning 

educational interventions in Level III cases, PROs should review all quality-of-care 

problems they have identifed on those physicians durig the life of their PRO 

contracts. ) 

Recmmendation 6: In response to this recommendation, HCF A references the 

epidemiologic evaluation and oversight that wi be emphasized in future contracts with 

PROs (using HCFA's Uniorm Cliical Data Set). Ths future direction cited by 

HCFA represents an important and potentially constructive redirection in the PRO 

program. It does not, however, respond to the point of our recommendation. 

In our recommendation, as in the report as a whole, we make it clear that we are 

focusing on physicians responsible for poor medical care--that is, those physicians who 

have confrmed Level III quality-of-care problems. Our recommendation urges HCF A 

to determine the effectiveness of the educational interventions undertaken against 

these physicians. What interventions work best for them? Under what circumstances? 

Why? These are important questions to answer and should not be confused with 

other important questions about how practice-related data can best be used to 

improve the performance of most practicing physicians. 

F ­

..

i, , .J l- DEPARTMENT OF HEALTH & HUMA SERVICES	 Puic He 

Memorandum 

NOV '9 1991 

Date 

From	 Assistant Secretary for Health 

S\Jbje	 Office of Inspector General (OIG) Draft Report "Educating Physicians Responsible for Poor Medical Care: A Review of the 

Peer Review Organizations ' Efforts, " OEI-Ol-89-00020 

Inspector General, OS


Attached are the Public Health Service comments on the subject draft report. We concur with the intent of the 

re commenda t ion. Howeve r, we re commend tha t the recommenda t ion be directed toward more appropriate organizations 8uch as the


Healch Resources and 
 ervices Admini8tration (HRSA), with technical assistance from the Agency for Health Care Policy


and Research. or perhaps to medical organizations and


professional societies themselves. In our comments we discuss 

some activities undertaken by HRSA in previous years that


could be responsive to the issues identified in this report. 

Attachment 

F ­

. .

PUBLIC HEALTH SERVICE (PHS) COMMENTS ON THE OFFICE OF

INSPECTOR GENERA (OIG) DRAT REPORT . EDUCATING PHYSICIANS 

RESPONSIBLE FOR POOR MEDICAL CAREI A REVIEW OF THE PEER 

REVIEW ORGANIZATIONS' EFFORTS. . OEI-OI-B9-00020 

General Comments


The draft report presents findings regarding the lack of


consistency and perceived value of Peer Review Organization


(PRO) educational interventions, and discusses the significant


barriers undermining these efforts. The recommendations are


designed, overall, to rationalize this system. We are


particularly supportive of efforts to involve hospitals (or


other appropriate facilities, such as nursing homes) in the


planning of educational efforts.


It is not clear, however, that intensified educational 

interventions by PROs will overcome the basic problems 

described in the report. Additional consideration needs to be 

given to ways to change the adversarial relationship between 

PROs and individual physicians, and to encourage more active

invol vement of a range of medical peers and professional 

organizations in the education and discipline of colleagues. 

OIG Recommendation 

The Public Health Service, through the Agency for Health Care


Policy and Research (AHCPR), should provide demonstration


funding for the establishment and refinement of medical


education programs that seek to enhance the clinical competence


of physicians through individualized assessment and remedial


! education.


PHS Comment


We agree with the intent of this recommendation, but note that 

there are several problems with it as currently drafted. AHCPR 

has the authority to fund -demonstrations, but is not currently 

doing so, nor are specific demonstration funds included in the

AHCPR budget . As part of its growing program to address issues 

related to quality assurance in health care, AHCPR hopes to

fund research, including demonstrations, designed to determine 

the effectiveness of alternative programs for improving 

physician performance and reducing the incidence of substandard 

medical care. This is consistent with the agency' s statutory authority to focus on research and evaluation questions. 

An evaluation of the effects of personalized assessment and


. remedial education programs on improved physician performance 

would be eligible for consideration in such an effort. 

However, the development and establishment of such programs is 

not wi thin the purview of the AHCPR. The recommendation 
should therefore be directed toward more appropriate 

organizations, such as the Health Services and Resources Administration (HRSA), or perhaps to medical organizations and professional societies themselves. AHCPR could provide


technical assistance to HRSA by reviewing methodologies and


evaluating proposals for demonstration funding.


HRSA' s Area Health Education Centers (AHEC) Program is 

authorized under section 781 (a)(1) and 781 (a)(2) of the 

Public Health Service Act. Under section 781 (a)(1), basic 

support in the form of cooperative agreements is provided to 

successful applicants (medical schools or their parent 

organizations) to carry out an AHEC Program in a region of' a 

State or in an entire State, over a ' 3- 9 year period. Under section 7B1 (a)(2), grant support is provided to former 

reci pien ts of 7 1 (a) ( 1) funds to carry out 2-year AHEC Special projects. Initiative projects, including innovative demonstration

Quality assurance has been one of the funding priorities


established for the AHEC Program and the AHEC Special


Initiatives Program during competitive cycles held in previous

years. In Fiscal Year (FY) 1992, quality assurance was not 

included as a funding priority, since substance abuse was added 

to the other funding priority areas: geriatrics, HIV-AIDS, and
 infant mortality prevention. We will reconsider whether quali ty assurance should be reestablished as one of the funding priori ties for the AHEC Program and the AHEC Special ! Initiatives Program beginning in the FY 1993 competitive grant cycle. This would encourage a range of quality assurance 

applications that would focus on physician effectiveness 

educational programs at a State or local level, and would be 

responsive to the needs and issues cited in the OIG draft

report. 

The AHEC Program appropriation in FY 1991 was $19. 2 million, with 90 percent of the funds ($17. 3M) awarded to support 15

ongoing AHEC programs and six new AHEC programs. Currently, to 10 percent of the annual AHEC Program appropriation may be 

used to support AHEC Special Initiatives projects. In FY 1991, a total of approximately $1. 9M was awarded to support

15 continuation and eight new Special Initiatives projects, some of which address quality assurance issues. The average award was $75, 000. 

TECHNICAL COMMENT


The name of the Agency for Health Care Policy and Research 

should be corrected in the recommendation to the Public Health 

Service on pages iii and 13 of the report. 

F ­
OIG REPONSE TO PHS COMM


In response to PHS' comments, we have amended our recommendation to clari that 

both the Agency for Health Care Policy and Research and the Area Health Education 

Centers Program in the Bureau of Health Professions could serve as resources to 

support and assess demonstration efforts cited. We have also made the techncal 

correction noted.


F ­

.\.. 

Brinlfin " lifftimts Oft:l:pooimcr and ltlldfrsl1ip to Sfn'/" all "mtratio", 

September 17, 1991


Richard P.
 usserow Inspector General 

Department of Health and Human Services 

330 Independence Ave., S. 

Washington, D.C. 20201 

Dear Mr. usserow: 

I am responding to your letter to Horace Deets regarding the


draft report entitled " Educating Physicians Responsible for Poor


Medical Care: A Review of the Peer Review Organizations'
 Efforts. The American Association of Retired Persons is very 

pleased to submi t these comments and commends the authors of the


-report for their contribution to increased understanding of how


to improve a program of great importance to Medicare
 beneficiaries. 

The report provides empi rical data indicating that the quali 

intervention plans pursued by the Peer Review Organizations 

(PROs) are falling far short of thei r goals. A major conclusion 

from the report is that, although PROs are effective in 

identifying Level III problems, they do not have an effective and 

consistent process for ameliorating deficiencies and certifying 

the competency of problem physicians. The report is also instructi ve in not only providing an inventory of the problems 

that lead to Level III citations, but in recognizing th 

frequently difficult environment in which remedies for such ci tations are considered. 

AARP continues to believe that a properly functioning peer review system provides vi tal protection for Medicare beneficiaries. 

Accordingly, every effort must be made to strengthen existing 

mechanisms for intervention in cases of poor quality. We have 

reviewed the draft report and find that, for the most part, we 

are in agreement wi th its recommendations and findings. Accordingly, the following comments address those areas where we 

have addi tional suggestions. 

Background ( pg. 2) 

We suggest that you reference the Office of the Inspector General' s (OIG) earlier report on PRO sanctions so that readers 

may be informed about the PROs' experience in exercising their more puni tive options for addressing quali ty of care problems. 

\rm:nc.1n .\ssexi;1ton of Retired Persom bOJ E Street. uhing:tnn. DC :!004Q :!o 

Runen B, 1.l::wel1 PrmdmT F - HorJ':c B. Dcct EX((/IT:Y DII' aror 
Recommendations ( pg 12 - 14) 

In its fi rst three recommendations, the OIG calls for: 

Ensuring timely educational interventions in all


confirmed Level III cases; 


Mandating sharing of case information with the hospitals


in which the problems occurred;


Encouraging the PROs to involve the hospitals in the


planning and conduct of the educational interventions.


We strongly endorse these recommendations. Wi th respect to the 

second, we note that this sharing, given the PROs existing 

discretionary authority, would not constitute a significant change in the current confidentiali ty and disclosure framework 

established in regulation. With respect to the third, hospital 

quali ty assurance commi ttees play a cri tical role nationally in 

maintaining quali ty of care, yet the report indicates 88\ had no 

part in PRO educational interventions. In light of the potential

importance of hospi tals' involvement, the OIG in its final report 

also should recommend that: 

o HcrA mandate PRO-hospi tal interaction wi th respect to both 

the planning and evaluation of interventions through changes in and in hospi tals' Condi tions of Participation. 

In addi tion, PROs should be encouraged to reach out and involve 

medical schools, medical centers, and other appropriate ! institutions in their areas in the design, implementation, and . evaluation of corrective action plans, including innovative

remedial education programs. In this connection, we note the

report' s observation that lack of access ,to medical seminars and 

other appropriate remedial courses is particularly acute in many rural areas. Particular attention should be paid to this

PRO regulations 

problem. 

In its fourth recommendation, the OIG stresses the value of 

personal meetings as an educational intervention. It is our 

understanding that considerable research is underway with respect 

to strategies for changing physician practice patterns which may 

be relevant to this issue. We concur that HcrA and the PROs 

should take into account research findings on how physicians 

learn in evaluating the efficacy of personal meetings and other interventions. 

The fifth recommendation points up a serious deficiency 

identi fied in the report, namely the PROs' failure to utili ze all 

available data affecting the judgment about a physician' performance. Accordingly, we strongly concur wi th the OIG' 

recommendation and additionally recommend that: 

Efforts by the PROs and HcrA to achieve PROs' access to


F ­
state medical licensure board information pertinent to


investigation of Level III cases should be accelerated. This


report again documents the reluctance of PROs and state boards to


communicate wi th each other in cases of 5e rious quali ty problems 

the barriers to such information sharing should be evaluated. 

PROs should be given authori ty to query the National


Practitioner Data Bank about specific physicians.


The OIG' s sixth recommendation, that HcrA obtain and disseminate


information on the effectiveness of PRO educational


interventions, has great meri
t. In order to implement this

recommendation uni formly across PROs, we also recommend that: 

o PROs should be instructed to prepare and document reports 

on the effectiveness of each Level III intervention. These 

reports would serve to communicate Important information to 

physicians and their hospitals, as well contribute to the


development of a HcrA data base on the impact of PRO
 interventions. 

We appreciate the opportuni ty to review this important report and 

to share our comments wi th you. If you should have any 

questions, please contact Mary Jo Gibson of the Division of

Legi slation and Public Policy at (202) 434-3896. 

n -
 othe r 

Dl rector 

Division of Legislation and Public policy


F ­

OIG REPONSE TO AA COMMNT 

In response to AAP' s comments, we have added a footnote referencing the prior 

OIG report on PRO sanctions and have modified our third recommendation to call for 

the PROs and HCF A to work together not only in planning and conducting 

educational interventions, but also in asssing them. 

With respect to AA' s additional recommendations: (1) we do not view it 

appropriate to recommend that PRO-hospital interactions be included in hospitals 

Medicare conditions of participation, given that our focus in this report has been on the PROs rather than hospitals; (2) we have addressed in a prior report the need for 

closer interactions between PROs and State medical boards (see "State Medical 

Boards and Medical Discipline " OEI-01-89-00560, August 1990); and (3) we agree 

that PROs should be able to query the National Practitioner Data Bank and 

understand that wi be the case once Section 5 of the Medicare and Medicaid 

Protection. Act of 1987 is implemented. 

F ­

.,:.. .;

'L\mi' AMERICAN MEDICAL PEER REVIEW ASSOCIATION

810 First Street. N. E. . Suite 410. . Washington, D.C. 20002 (202) 371-5610 . M: (202) 371-8954 

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September 30, 1991 

Richard Kusserow 

Inpector General


Deparent of Health and Human Servces 

HHS Cohen Buildig 

Room 525(; 

330 Independence Avenue, S. 

Washigton, DC 20201


Dear Mr. Kusserow:


The American Medica Peer Review Assocation (AMRA) appreciates the 

opportty to respond to the prepublication dr report entitled, "Educatig 

Physician for Poor Medica Cae: A Review of the Peer Review Organtions 

Effort." The draf has not been shared with the AMRA membership nor dicused 

by the AMRA Board of Directors. The followig comments, therefore, should be 

viewed as preliar and not reflectve of AMRA Board policy at th tie. 

AMRA is supportve of the report's recommendations and believe adoption would 

enhance the PRO's effort to modi the behavior of individual practtioners. 

parcuar, we support tberecommendation requg PROs to share inormation with 

the hospitals about Level il caes attrbuted to physician. We would suggest going 

one step fuher and mandate that al confed qualty problems be shared with

hospital. We believe that hospita are legaly responsible for the qualty of cae 

delivered in their intitutions and, therefore, should be entitled to inormation 

relating to confed qualty problems identied by the PRO. 

We are also strongly supportve of the recommendation to encourage PROs to 

involve hospital in the plang and conduct of educational interventions. We 

believe that this would greatly enbance the educational impact by PROs. In the past, 

HCFA General Counel has taken the position that to share specifics of PRO 

intervention with the facity would requie a waiver of the confdentialty proviions 

by the afected physician. 

The recommendation that PROs be mandated to tae into account al previous 

qualty of cae probJems when diectg an educational intervention for a physician 

makes good sense. HCFA should consider requig PROs to maitain a capacity 

to profie qualty of care problems by individual practtioner over the term of a PRO 

contract and not just for consecutive quarers which is tbe mandate at present. 

F ­
$

(,(

Richard Kusserow


September 30, 1991 

Page two 

Once agai than you for tbe opportty to comment on th draf report AMRA looks 

report for distrbution to the AMRA membership. forward to receivig the fial 


Sincerely, 

Andrew Webber 

Executive Vice President 

AW/aw 

F ­

OIG REPONSE TO AMRA COMM 

We agree with AMRA' s point that all quality problems be shared with hospitals and 

suggest that HCFA consider it. However, given our study s focus on Level III cases 

and educational interventions, we must limit our formal recommendations accordingly. 

We also agree with AMRA' s point about HCFA requirg the PROs to maintain a 

capacity to profie quality-of-care problems by an, individual practitioner over the term 

of a PRO contract. We have reinforced this point in our response to HCFA and have 

amended the recommendation to clarify that this profiling requirement should apply 

for the life of a PRO contract. 

F ­

American Medical Association 

Physicians dedicated to the health of America 

James S. Todd. MD 515 North State Stret 312464-500


Executive Vice Preident Chicago. Illois 60610 312 464-4184 Fax


September 9, 1991


Richard P. Kusserow 

Office of Inspector General 

Department of Heal th and Human Services 

200 Independence Avenue, SW

Washington, DC 20201 

RE: Draft Report - "Educat ing Phys icians 

Responsible For Poor Medical Care: 

A Review of the Peer Review Organizat ions I 

Efforts tJ/-f'i- 1J.;6 

Dear Mr. Kusserow:


The American Medical Association (AM) welcomes the opportuni ty to 

comment on the draft report, "Educat ing Phys icians Responsible For Poor 

Medical Care: A Review of the Peer Review Organizat ions I Efforts. 

The AM commends the Office of Inspector General for undertaking the 

examination of current educational activities of PROs. We support the 

goal of the peer review organizat ion (PRO) program, to ensure qual i ty 

medical care for all Medicare beneficiaries, and we believe it can best 

be achieved by di rect ing current PRO resources toward educat ional and 

quality assurance endeavors rather than punitive interventions. 

The Omnibus Budget Reconci I iat ion Act of 1990 (OBRA ' 90) provides that 

before a PRO submi 15 its report and recommendations to the Secretary of 

Heal th and Human Services pursuant to the Qual i ty Intervent ion Plan of 

the Heal th Care Financing Admini strat ion (HCFA), the PR may provide the 

physician or entity being scrutinized an opportunity to enter into and 

complete a corrective action plan (CAP). The CA may include remedial


education, if appropriate. In our view , however, PROs should not


uni laterally develop or be involved in the actual provision of an


educational CA, nor should they be involved directly in a system for


coordinating the educational activity.


PRO ent i ties do not possess the necessary educational resources, facul 

or expert i se to engage in such an endeavor. Any such act ions by the PROs 

would also constitute a serious conflict of interest, especially if 

undertaken as a revenue generating activity. We believe, moreover, that 

PROs must not mandate or require the use of any specific educational 

program or resource by physicians designated through the problem 

ident if icat ion process. Ins tead, the PRO should recognize the resources 

already available within the community and rely on those institutions to 

provide educat ional programs and remediat ion. 

F ­

- 2 ­


The following analysis of the recommendations set forth in the draft


report wi 11 present the AM t s views on appropriate PRO act ivi ties to 

correct deficiencies in technique or pract ice that affect the qual i ty 


medical services rendered. 

Recommendation 1 - The Health Care Finacing Administration should 

ensure that the PRs initiate ti.ely educational interventions in all 

confirmed Level III cases. unless the physician surrenders hislher .edical license. 

The AM believes that the recommendation should be modified by deleting 

the phrase which states, "unless the physician surrenders his/her medical 

license. Such a recommendation appears contrary to the intent of the 

draft report which attempts " to assess the educational interventions that 

the Medicare- funded Peer Review Organizat ions (PRs) direct to phys icians 

The phrase in responsible for serious quality of care problems.


quest ion, however, impl ies that PROs may. impose a puni t ive or coercive


measure. rather than an educat ional strategy, to induce a physician to 

surrender his/her medical icense. .Deletion of the phrase "unless the 

physician surrenders his/her medical license" would eliminate the, 

impl ication that a physician may be encouraged to surrender his or her ini tiate an educational icense. and a PRO would not be required to 


intervention (based on timeliness) in situations where a license 


surrendered. 

Recommendat ion 2 - The Heal th Care Financing Administration should PR share case .andate that for all confirmed Level III cases, the 

infornt ion wi th the hospi tals at wbich the problems occurred. Tht 

information should include the identity of tbe physician. the nature 

of the problem . and the type of educational and other interventions 

imposed by the PR. 

PROs should institute an approach to the notification process in sharing 

confirmed Level III information with hospitals that will maximize the 

educat ional impact of the program. The AM has urged HCFA to modi 

current regulat ions so that:, (1) in regard to confirmed qua Ii ty problems 

i ty Assurance which have been finally adjuaicated by the PRO Qual 


Committee, the PRO is required to notify both the physician and president 

of the hospital medical staff in all such cases; and (2) the PRO is 

requi red to implement a mechanism to veri fy receipt of the PRO' s not ice 

of both potential and confirmed quality problems by the physician. We


have further recommended amendments to the PRO statute: (1) to require


at when the PRO review goes beyond the generic screen for intensified 

review , the phys ician mus t be not i fied wi thin 48 hours of the exact 

reason for said review; and (2) to repeal the existing prohibi tion on the 

release (to a PRO proposed sanctioned physician) of documents or other


information produced by a PRO in connection with its deliberations in


making qual i ty determinat ions. The AM al so recommends that HCFA 

regulations be revised to permit notification to residency training 

programs of a Quality Intervention Plan letter of inquiry received by a 

res ident during part icipat ion in an accredi ted res idency program. 

Prior to confirmation of a quality problem by the PRO, notification


should occur only at the request of/or with the consent of the affected


F ­
- 3 ­


phys ician. The AM opposes di sclosure of unconfirmed PR qual i ty 

inquiries as this would unfairly impinge on a physician s right to 

privacy and confidentiality and also deleteriously affect the physician

profess ional reputat ion. 

Recommendat ion 3 - The Heal th Care Finacing Adainistration should 

encourage the PRs to involve the hospitals in the planing and 

conduct of the educational interventions. 

The recommendat ion to encourage PRs to involve hospi tal s in the planning 

and conduct of the educat ional intervent ions requires further 

specification. It is essential that a CA apply only to the physician 

ident i fied as the source of the confirmed qual i ty problem. Evidence 

rge suggests that, in certain instances, a PR has required all or a 

portion of a facility s active medical or other professional staff to be 

involved in a focused CA which should have been more precisely directed 

to the ident i fied phys ician. The AM stands opposed to CAs of an 

intrusive and overly expansive nature. Also, in recognizing hospital 

involvement in the planing and conduct of educational interventions, it 

should be clarified that such involvement is to include the organized 

medical staff and not jus t the hospi tal administrat ion. 

Recommendat ion 4 - The HeaUhCare Financing Adainistration should 

instruct the PRs to give greater attention to personal .eetings as 

an educat ional intervent ion and to explore ways of conductingIII one- to-one .eetings between physicians with confir.ed Level 


qual i ty-of-care problems and physician consul tants.


The AM supports the concept of increased personal meetings between

tool. physicians and physician consultants as a constructive educational 

Physicians have expressed repea1 d frustrat ions at their inabi 1 i ty to 

contact and meet wi th a pbys ician representat ive of a PRO. these Implementation of Recommendation 4 would be of value in mitigating 


concerns. 

Consistent with our view that PROs should limit their activities in 

developing CAPs to the idendfication of confirmed problems and 

notification thereof, as well as monitoring compliance with a CA, we 

bel ieve that the PRO should not uni laterally be involved in determining 

an educational CAP, providing such education or requiring the use of a

specific educational program. The PRO, therefore, should not participate 

in any form of instructional arrangement between the cited practitioner problem. and an independent educational program selected to remediate the 


Recommendat ion 5 - The Heal th Care Financing Administration should 

aadate that before directing an educational intervention to a

physician, the PRs take into account all prior qulity-of-care problems they have ident i fied concerning that physician. 

When the PRO considers prior quality of care problems, the AM believes 

that it would be useful to evaluate only those cases that relate directly 

to the confirmed quality problem at hand. An arbitrary review of all 

F ­

- 4 ­


previous unre lated qual i ty quest ions would not serve to correct technical 

deficiencies in technique or procedure that have been revealed by the 

current Level III confirmed quality problem under scrutiny. 

Recommendation 6 - The Health Care Financing Adainistration should


obtain and disse.inate inforaation on the effectiveness of 


educational interventions. 

PROs generally lack the expertise, resources and faculty to provide the 

necessary assessment, educat ion and evaluat ion of those educat ional 

intervent ions undertaken by phys icians ident i fied in the Qual i ty 

Intervention Plan. It may be appropriate, however, to monitor the 

referral of physicians to appropriate educational programs or 

institutions, as well as the evaluation by the relevant educational 

program of the phys ician ' s progress. 

In addition, we believe that the PRO program should be redesigned to 

provide rout ine feedback to the medical communi ty about its review 

findings. PROs should be required to distribute aggregate information on 

a regular basis to state medical societies. Provision of such 

educat ional feedback is essent ial to improvi g qual i ty of care for the 

Medicare population and others. Sharing of aggregated information at the


state level would enable physician organizations to identify specific


areas for which educat ional material s or programs could be developed or


provided. 

for Recommendation 7 - The Public Health Service, through the Agen


Heal th Care Pol i and Research, should provide demonstration funding 

for the establishaent and refinement of .edical education prograas


that seek to enhce the clinical coapetence of physicians through 

individualized assess.ents and remedial education.


The AM supports funding for demonstration grants to implement the intent 

of Recommendation 7. Such grants should be awarded to educational 

institutions with the ability to provide individualized physician 

assessment, necessary education, and evaluation. PROs, however, should 

not be the recipients of sucID educat ional grants. 

Wi th respect to the comment in the draft report indicating few avai lable 

educat ional programs for address ing medical pract ice deficiencies, 

wish to point out areas where substantial progress has been made in the


last two years. The AM has compi led and maintains a national registry 

of focused/remedial educat ion programs. A task force comprised of 

cont inuing medical educat ion providers, I icens ing bodies, 

representatives and others has been assembled to meet on a regular basis 

to assess progress in this area. To date, the national registry has not 

been contacted by a PRO or by HCFA regarding informat ion about a speci fic 

medical educat ion program. 

In conclusion, the AM applauds your effort to assess educational 

interventions of PROs as articulated in the draft report. We believe 

that educat ional CAPs which minimize undue disrupt ion of the phys ician ' s 
- s ­


practice, incorporate principles of fairness and due process, and serve will to truly provide an educational approach to quality intervention 


bes t serve the interests of our pat ients. We would be pleased to work


I ines to improve wi th HCFA and others to formulate principles and guide 


the effect i veness of the PRO program in this area and thereby enhance the 

qual i ty of medical care provided to Medicare beneficiaries.


Sincerely, 

d-ml) ,E. 

James S. Todd, MD


JST:hl 

F ­

OIG REPONSE TO AM COMMNT 

We agree with the AM that the PROs' own role in conducting educational activities 

should be limited. It is for that reason that we recommend that HCF A involve 

hospitals more in the educational activities and that PHS provide demonstration 

funding for medical education programs that seek to enhance the clinical competence 

of physicians through individualied assessments and remedial education. 

With respect to the AM' s comments on each of our seven recommendations, we 

respond as follows: 

Recmmendation 1: In accord with the AM' s suggestion, we omitted the phrase 

unless the physician surrenders his/her medical license" from the recommendation. 

We moved it to a less promient place in the supporting text, not to imply that the 

PROs "may impose a punitive or coercive measure," but simply to clarify that an 

educational intervention is obviously unnecessary in cases where physicians of their 

own accord have chosen to surrender their license. 

Recmmendation 2: The AM presents its position on a number of issues concerning 

the PRO review process, but does not comment directly on our recommendation 

mandating that information on confrmed Level III cases be shared with the hospitals. 

It does urge that HCF A take an approach in sharig Level III inormation with 

hospitals that "will maxmize the educational impact of the program." Our 

recommendation, if implemented, would faciltate the fulfent of that objective. 

Recmmendation 3: In accord with the AM' s suggestion, we have amended the 

recommendation to specify that it applies to Level III cases. As to which parties 

should be involved in representing the hospital, we would regard a hospital quality 

assurance committee as being the focal point, but look to HCF A to provide the 

appropriate specification. 


Recmmendation 4: We share the AM' s concern that the process of developing an 

educational intervention be a collaborative one. However, given the lited nature of 

the educational actions that we have found PROs take in Level III cases, we would 

not lessen the PRO's authority to determine an appropriate educational intervention 

or to obtain feedback concerning that intervention. 

Recmmendation 5: In callng for the PROs to consider prior quality-of-care 

problems involving a physician with a confirmed Level III problem, we are not at all 

callng for "an arbitrary review of all previous unrelated quality questions." To the 

contrary, we are urgig the PROs to have before them relevant information 

concerning a physician s -performance - information that can help them craft an 

educational intervention suited to a physician s particular needs. Such information 

could reveal a certain pattern of problems that could be quite helpful to the PROs 

and eventually to the physician. This approach is in accord with the AM' s desire 

F ­

that the PROs maxmize their educational impact. Accordingly, we urge the AM 

reconsider its position on this recommendation. 

Recmmendation 6: We recognze that the PROs lack resources or expertise to 

conduct in-depth assessments of their educational interventions in Level III cases. It is 

for that reason that we urge HCF A to address the issue directly by supporting 

research efforts and identifng ways of obtaining and dissemiating information on 

this vital matter. Ths tye of information is important in its own right, and should not 

be confused with information on the effects of more generalized effort to disseminate 

practice-related information to the medical community. 

Recmmendation 7: To clarify, we do not urge that the PROs be the recipients of 

demonstration funding for the establishment and refiement of medical education 

programs. Rather, our intent here is to increase the availabilty of signcant 

educational vehicles available both to PROs and physicians. Finally, in accord with the 

information provided by the AM we have added a recommendation calling for 

HCFA to obtain and distribute to all the PROs information about the 

focused/remedial education programs included in the AM' s national registry. 

F ­

APPENDIX G


ENDNOTE 

The PROs must also total the weighted severity scores for each institutional 

provider identifed as having one or more quality-of-care problems. We have 

excluded such proviqers, which, according to HCF A, account for about 20 

percent of all confrmed quality-of-care problems, from the scope of this study. 

The weighted severity score triggers specific interventions which the PRO must 

impose. At a minium, HCF A requires the PROs to use the followig 

interventions at the noted weighted triggers: 

Intervention Weighted Trigger 

Notification


Education


Intensified Review


Other Interventions 

Consider Coordinating with


Licensing Bodies 

Consider Recommending 

Sanction 

Because the PROs must apply these interventions in a cumulative manner, a 

physician responsible for a confrmed Level III quality-of-care problem, which 

has a weight of 25, would be subject to each intervention. 

In an October 1988 report entitled "The Utiltion and Quality Control Peer 

Review Organition (PRO) Program: Sanction Activities" (OAI-01-88-00571), 

we focused on the PROs' sanction activities in some detail. One of our findings 

cited in that report was that conflct between the PROs' concurrent education 

and sanction roles appeared to undermine the effectiveness of the sanction 

process. 

Physician specialty does not indicate board certification in this context. Rather 

it is the specialty reported by the physician to the American Medical 

Association which accounts for the greatest number of professional hours. 

Non-Federal physicians are those not employed by the Federal Governent 

i.e., the Ary, Navy, Air Force, Department of Veterans' Afairs, the Public 

Health Servce, and other federally funded agencies. 

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10. 

11. 

12. 

13. 

14. 

15. 

16. 

Chi-square = 14.5, dJ. = 3, and p c: .005. 

Chi-square = 55.4, dJ. = 4, and p c: .005. 

Excluding osteopaths. 

By additional, we mean other than the confirmed Level III quality-of-care 

problem reviewed in our sample. 

To describe the serious quality-of-care problems, we recorded the generic 

quality screen failures for each. Generic quality screens are criteria applied to 

the medical records for identifyg events that could indicate poor quality of 

care. We found that the screen failures clustered in 2 of the 20 screens HCFA 

requires the PROs to apply: (1) care or lack of care resulting in serious or 

potentially serious complications, and (2) abnormal diagnostic fidings which 

are not addressed and resolved or where the record does not explain why they 

are not resolved. See appendix D for more information on generic quality 

screens. 

The intensified reviews ranged from the next 10 cases with a particular 

diagnosis or procedure to 100 percent of all cases for a three-month period. 

many cases, the PRO kept a physician on intensifed review for three months 

following the ,completion of the educational intervention. 

According to this PRO, its practice of retrospective reviews prior to imposing 

an educational intervention has since changed, and interventions will now be 

imposed within 30 days followig notifcation. 

At that time, imposing an educational intervention could undermne the 

sanction recommendation by indicating the physician was willing and able to 

change. An amendment in the 1990 Omnibus Budget Reconcilation Act 

stipulates that a physician s failure to comply with a PRO's educational 

interventions can be considered evidence of his or her unwiingness and 

inabilty to change, thereby not interfering with the sanction recommendation. 

PRO officials tyically consider a quality-of-care problem resolved when the 

intensified review revealed no further problems in the quarter following the 

interventions. 

Institute of Medicine Medicare: A Strategy for Quality Assurance Vol. 1 

(Washington, D. : National Academy Press, 1990). 

All in Medicare: A Strategy for Quality Assurance: F. Davidoff, R. Goodspeed 

and J. Clive; "Changing Test Orderig Behavior: A Randomized Controlled 

Trial Comparing Probabilstic Reasoning with Cost-Containment Education 

Medical Care 27 (1989): 45-58; J.M. Eisenberg, Doctor s Decision and the Cost 

of Medical Care (An Arbor, Mich.: Health Administration Press, 1986); K. 

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, 

Lohr, J.D. Winkler, and R.H. Brook Peer Review and Technology Assessment in 

2820-0TA (Santa Monica, Calif.: RAD Corporation, 1981); S. 

Schroeder Strategies for Reducing Medical Costs by Changing Physicians 

Behavior International Journal of Technology Assessment in Health Care 

(1987): 39-50. 16. 

Medicine, 

17. Office of Inspector General Medical Licensure and Discipline: An Overview 

June 1986, and Offce of Inspector General State Medical Boards and Medical 

Discipline, August 1990.

18.	 The National Practitioner Data Bank operates under Title IV of the Health 

Care Quality Improvement Act of 1986 (PL 99-660). 

19.	 Ths conflct has existed from the begig of the PRO program and its 

predecessor, the Professional Standards Review Organization program. See 

Medicare: A Strategy for Quality Assurance, pp. 145-147, op. cit. 

20.	 American Medical AssoCiation Report of the Council on Medical Education: 

Focused Continuing Medical Education Programs for Enhanced Clinical 

Competence, (1-89). 

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